Provider Demographics
NPI:1316688435
Name:DICKERSON, ALEXANDER JOHN
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:JOHN
Last Name:DICKERSON
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 1:228 BEEMAN PL
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-7009
Mailing Address - Country:US
Mailing Address - Phone:314-403-3045
Mailing Address - Fax:
Practice Address - Street 1:228 BEEMAN PL
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-7009
Practice Address - Country:US
Practice Address - Phone:314-403-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist