Provider Demographics
NPI:1629351994
Name:DICKSON, NANA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NANA
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 WILLIAMS DR
Mailing Address - Street 2:STE. #201
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-419-6897
Mailing Address - Fax:571-419-6889
Practice Address - Street 1:3040 WILLIAMS DR
Practice Address - Street 2:STE. #201
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4618
Practice Address - Country:US
Practice Address - Phone:571-419-6897
Practice Address - Fax:571-419-6889
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2015-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14996122300000X
DCDEN1001083122300000X
VA04014142771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist