Provider Demographics
NPI:1740522655
Name:DICKSON, KING DAVID
Entity type:Individual
Prefix:
First Name:KING
Middle Name:DAVID
Last Name:DICKSON
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 1:6248 LAKELAND AVE N
Mailing Address - Street 2:SUITE 211
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55428-2986
Mailing Address - Country:US
Mailing Address - Phone:763-245-1786
Mailing Address - Fax:
Practice Address - Street 1:6248 LAKELAND AVE N
Practice Address - Street 2:SUITE 211
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55428-2986
Practice Address - Country:US
Practice Address - Phone:763-245-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 210393-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse