Healthcare Provider Details

I. General information

NPI: 1679569537
Provider Name (Legal Business Name): JERRY W. DICKSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ALLISON AVE
CHANDLER OK
74834-3834
US

IV. Provider business mailing address

PO BOX 489
CHANDLER OK
74834-0489
US

V. Phone/Fax

Practice location:
  • Phone: 405-258-1042
  • Fax: 405-258-5009
Mailing address:
  • Phone: 405-258-1042
  • Fax: 405-258-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4968
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: