Healthcare Provider Details

I. General information

NPI: 1497746796
Provider Name (Legal Business Name): JAMES LEWIS DICKSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BERRYWOOD DR
COLUMBIA TN
38401-6408
US

IV. Provider business mailing address

104 BERRYWOOD DR
COLUMBIA TN
38401-6408
US

V. Phone/Fax

Practice location:
  • Phone: 931-380-1101
  • Fax: 931-380-9172
Mailing address:
  • Phone: 931-380-1101
  • Fax: 931-380-9172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2313
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: