Provider Demographics
NPI:1699308130
Name:DICKINSON, IAN ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:ROBERT
Last Name:DICKINSON
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 1:805 SE 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2232
Mailing Address - Country:US
Mailing Address - Phone:707-280-1901
Mailing Address - Fax:
Practice Address - Street 1:12750 SE STARK ST BLDG E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:971-347-3009
Practice Address - Fax:971-256-3277
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1047201223G0001X
ORD114121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-5100OtherIDAHO DENTAL LICENSE
CADDS104720OtherCALIFORNIA DENTAL LICENSE