Provider Demographics
NPI:1952985574
Name:DICKOVICH, MADISON RAE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:RAE
Last Name:DICKOVICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16299 STEMMER RIDGE RD NW
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-9476
Mailing Address - Country:US
Mailing Address - Phone:952-797-3238
Mailing Address - Fax:
Practice Address - Street 1:2056 SUPERIOR DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-5024
Practice Address - Country:US
Practice Address - Phone:507-315-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND145841223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program