Provider Demographics
NPI:1659032944
Name:DICKEN, ALEXANDER TIMOTHY
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:TIMOTHY
Last Name:DICKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48708-7854
Mailing Address - Country:US
Mailing Address - Phone:989-893-5200
Mailing Address - Fax:
Practice Address - Street 1:500 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-7854
Practice Address - Country:US
Practice Address - Phone:989-893-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P041184146N00000X
MI5303039917183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1516581120Medicaid