Provider Demographics
NPI:1366531402
Name:DICKERSON, DERRICK J (DMD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:J
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Mailing Address - Street 2:203
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-218-6030
Mailing Address - Fax:480-218-6057
Practice Address - Street 1:6755 E SUPERSTITION SPRINGS BLVD
Practice Address - Street 2:203
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-218-6030
Practice Address - Fax:480-218-6057
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice