Healthcare Provider Details

I. General information

NPI: 1902237472
Provider Name (Legal Business Name): CHESTER DICKERSON DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 12/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 JACKIE RD SE SUITE 102
RIO RANCHO NM
87124-1519
US

IV. Provider business mailing address

5903 ASPEN AVE NE
ALBUQUERQUE NM
87110-5217
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-6965
  • Fax: 505-217-3791
Mailing address:
  • Phone: 512-550-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1106
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: