Provider Demographics
NPI:1992871461
Name:DICKIESON, PAMELA JANE (DDS)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JANE
Last Name:DICKIESON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2115
Mailing Address - Country:US
Mailing Address - Phone:313-562-4625
Mailing Address - Fax:
Practice Address - Street 1:22615 MICHIGAN AVE
Practice Address - Street 2:WEST VILLAGE DENTAL CARE
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2115
Practice Address - Country:US
Practice Address - Phone:313-563-4466
Practice Address - Fax:313-563-1266
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010155131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice