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General NPI Number Information
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NPI Number | 1629242896
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Entity Type | Individual
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Provider Name | CHRISTOPHER BRADLEY DICKERSON DDS, MD
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Gender | Male
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Dates
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Enumeration Date | 04/17/2008
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Last Update Date | 06/15/2020
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Provider Practice Location Address
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Address Line | 363 LAKEVIEW CT
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City | COVINGTON
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State | LA
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Zip | 70433-7515
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Country | US
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Telephone | 985-641-2030
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Fax | 985-900-2189
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Provider Business Mailing Address
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Address Line | 363 LAKEVIEW CT
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City | COVINGTON
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State | LA
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Zip | 70433-7515
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Country | US
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Telephone | 985-641-2030
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Fax | 985-900-2189
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 5714
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License Number State | LA
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