Provider Demographics
NPI:1134391436
Name:DICK, DELWYN LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:DELWYN
Middle Name:LEE
Last Name:DICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7892
Mailing Address - Country:US
Mailing Address - Phone:208-762-8750
Mailing Address - Fax:208-762-2530
Practice Address - Street 1:555 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7892
Practice Address - Country:US
Practice Address - Phone:208-762-8750
Practice Address - Fax:208-762-2530
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-30491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice