Provider Demographics
NPI:1700962792
Name:DICKSON, JON HUGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:HUGH
Last Name:DICKSON
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:PO BOX 1897
Mailing Address - Street 2:
Mailing Address - City:TAHOE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96145-1897
Mailing Address - Country:US
Mailing Address - Phone:530-583-2349
Mailing Address - Fax:530-583-6745
Practice Address - Street 1:605 WEST LAKE BLVD.
Practice Address - Street 2:SUITE 1
Practice Address - City:TAHOE CITY
Practice Address - State:CA
Practice Address - Zip Code:96145-1897
Practice Address - Country:US
Practice Address - Phone:530-583-2349
Practice Address - Fax:530-583-6745
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0328221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
925720OtherUNITED CONCORDIA