Provider Demographics
NPI:1538646732
Name:DICKERSON, CHAD JARRETT (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:JARRETT
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 E FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4241
Mailing Address - Country:US
Mailing Address - Phone:704-396-6166
Mailing Address - Fax:
Practice Address - Street 1:816 E FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4241
Practice Address - Country:US
Practice Address - Phone:704-396-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC111531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice