Healthcare Provider Details

I. General information

NPI: 1194168328
Provider Name (Legal Business Name): RAYMOND CHARLES DICKEY JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 FIRST NATIONAL DR
DALLAS GA
30157-3430
US

IV. Provider business mailing address

85 GOLF CREST DR STE 209
ACWORTH GA
30101-2698
US

V. Phone/Fax

Practice location:
  • Phone: 770-672-5629
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2019013206
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN014642
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: