Healthcare Provider Details

I. General information

NPI: 1740938992
Provider Name (Legal Business Name): COREY DICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5189
US

IV. Provider business mailing address

1431 FITZWATER ST UNIT 1
PHILADELPHIA PA
19146-2290
US

V. Phone/Fax

Practice location:
  • Phone: 800-836-7536
  • Fax:
Mailing address:
  • Phone: 301-821-0046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS044551
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: