Healthcare Provider Details

I. General information

NPI: 1336597558
Provider Name (Legal Business Name): DONALD REED DICKINSON III DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 08/29/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S MOUNT VERNON AVE
COLTON CA
92324-4255
US

IV. Provider business mailing address

601 E YORBA LINDA BLVD
PLACENTIA CA
92870-3006
US

V. Phone/Fax

Practice location:
  • Phone: 909-801-8144
  • Fax:
Mailing address:
  • Phone: 714-376-1876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number100209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: