Provider Demographics
NPI:1538321716
Name:JERRY W. DICKSON D.D.S., INC.
Entity Type:Organization
Organization Name:JERRY W. DICKSON D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-258-1042
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-0489
Mailing Address - Country:US
Mailing Address - Phone:405-258-1042
Mailing Address - Fax:405-258-5009
Practice Address - Street 1:820 ALLISON AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-3834
Practice Address - Country:US
Practice Address - Phone:405-258-1042
Practice Address - Fax:405-258-5009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100090810 AMedicaid