Provider Demographics
NPI:1497974844
Name:DICKERSON, NATHAN CHARLTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:CHARLTON
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 HILLRISE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4702
Mailing Address - Country:US
Mailing Address - Phone:505-522-0821
Mailing Address - Fax:505-521-3556
Practice Address - Street 1:2918 HILLRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4702
Practice Address - Country:US
Practice Address - Phone:505-522-0821
Practice Address - Fax:505-521-3556
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD16011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery