Healthcare Provider Details

I. General information

NPI: 1013782077
Provider Name (Legal Business Name): MICAH DICKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 MINNESOTA AVE NE
WASHINGTON DC
20019-2662
US

IV. Provider business mailing address

6711 S SEPULVEDA BLVD
LOS ANGELES CA
90045-2782
US

V. Phone/Fax

Practice location:
  • Phone: 312-274-4530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN2000422
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401419305
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: