Provider Demographics
NPI:1154044386
Name:DICKERSON ORTHODONTICS AND PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:DICKERSON ORTHODONTICS AND PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-799-4093
Mailing Address - Street 1:1200 W WARNER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2758
Mailing Address - Country:US
Mailing Address - Phone:480-963-2535
Mailing Address - Fax:
Practice Address - Street 1:1200 W WARNER RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2758
Practice Address - Country:US
Practice Address - Phone:480-963-2535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental