Provider Demographics
NPI:1619225307
Name:DICKERSON, MICHAEL SHUMWAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHUMWAY
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 1:2233 W BASELINE RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1039
Mailing Address - Country:US
Mailing Address - Phone:602-438-9245
Mailing Address - Fax:602-438-8695
Practice Address - Street 1:2233 W BASELINE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1039
Practice Address - Country:US
Practice Address - Phone:602-438-9245
Practice Address - Fax:602-438-8695
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0085581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice