Healthcare Provider Details

I. General information

NPI: 1649247123
Provider Name (Legal Business Name): ALAN CONRAD DICKERSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

IV. Provider business mailing address

1100 WILFORD HALL LOOP BLDG 4554
JBSA LACKLAND TX
78236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-0672
  • Fax:
Mailing address:
  • Phone: 210-292-0672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number4330
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: