Provider Demographics
NPI:1558493460
Name:DICKERSON ENTERPRISES, INCORPORATED
Entity Type:Organization
Organization Name:DICKERSON ENTERPRISES, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-218-6030
Mailing Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4373
Mailing Address - Country:US
Mailing Address - Phone:480-218-6030
Mailing Address - Fax:480-218-6057
Practice Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4373
Practice Address - Country:US
Practice Address - Phone:480-218-6030
Practice Address - Fax:480-218-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4940122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty