MEDICARE: DR. JERRY W. DICKSON D.D.S.

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	122300000X	Dentist	4968	OK

General Provider Information

NPI Number	:	1679569537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY W. DICKSON D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 489
Second Line	:
City	:	CHANDLER
State	:	OK
Zip	:	74834-0489
Country	:	US
Telephone Number	:	405-258-1042
Fax Number	:	405-258-5009

Provider Business Practice Location Address
First Line	:	820 ALLISON AVE
Second Line	:
City	:	CHANDLER
State	:	OK
Zip	:	74834-3834
Country	:	US
Telephone Number	:	405-258-1042
Fax Number	:	405-258-5009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	07/08/2007

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