Provider Demographics
NPI:1205996915
Name:DICKINSON, AARON KENT (LD)
Entity type:Individual
Prefix:MR
First Name:AARON
Middle Name:KENT
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-2881
Mailing Address - Fax:208-743-0719
Practice Address - Street 1:330 5TH STREET
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-2881
Practice Address - Fax:208-743-0719
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD33122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002560200Medicaid