MEDICARE: THOMAS R DICKSON, DDS., PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	264648	UT

General Provider Information

NPI Number	:	1588058960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS R DICKSON, DDS., PC

Provider Business Mailing Address
First Line	:	714 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-2347
Country	:	US
Telephone Number	:	801-567-0343
Fax Number	:	801-566-5725

Provider Business Practice Location Address
First Line	:	714 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-2347
Country	:	US
Telephone Number	:	801-567-0343
Fax Number	:	801-566-5725

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	DR. THOMAS R DICKSON
Credential	:	DDS
Telephone Number	:	801-567-0343

Provider Enumeration Date	:	03/24/2015
Last Update Date	:	03/24/2015

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