Provider Demographics
NPI:1629242896
Name:DICKERSON, CHRISTOPHER BRADLEY (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:BRADLEY
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7515
Mailing Address - Country:US
Mailing Address - Phone:985-641-2030
Mailing Address - Fax:985-900-2189
Practice Address - Street 1:363 LAKEVIEW CT
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7515
Practice Address - Country:US
Practice Address - Phone:985-641-2030
Practice Address - Fax:985-900-2189
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA57141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA29783Medicaid