Basic Information
| Provider Information | |||||||||
| NPI: | 1215902002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10662 BLACK KETTLE WAY | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809085202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | PETERSON AFB, BLD 950 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195561333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 05/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5376 | OK | Y | Dental Providers | Dentist |
No ID Information.