Healthcare Provider Details

I. General information

NPI: 1083697759
Provider Name (Legal Business Name): LISA MARIE DICKENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: LISA MARIE WILLETT DDS

II. Dates (important events)

Enumeration Date: 11/27/2005
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 NOTRE DAME BLVD 350
CHICO CA
95928-7161
US

IV. Provider business mailing address

2485 NOTRE DAME BLVD STE 350
CHICO CA
95928-7163
US

V. Phone/Fax

Practice location:
  • Phone: 530-343-5455
  • Fax: 530-343-9357
Mailing address:
  • Phone: 530-343-5455
  • Fax: 530-924-4148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: