Provider Demographics
NPI:1679569537
Name:DICKSON, JERRY W (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:DICKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-0489
Mailing Address - Country:US
Mailing Address - Phone:405-258-1042
Mailing Address - Fax:405-258-5009
Practice Address - Street 1:820 ALLISON AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-3834
Practice Address - Country:US
Practice Address - Phone:405-258-1042
Practice Address - Fax:405-258-5009
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4968122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist