Provider Demographics
NPI:1508419698
Name:RICKSON, DEREK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:T
Last Name:RICKSON
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 1:542 S 850 E
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-2549
Mailing Address - Country:US
Mailing Address - Phone:435-764-8618
Mailing Address - Fax:
Practice Address - Street 1:1451 N 200 E STE 200
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7565
Practice Address - Country:US
Practice Address - Phone:435-258-9039
Practice Address - Fax:435-787-1741
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11773797-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist