Basic Information
| Provider Information | |||||||||
| NPI: | 1780119867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DENHART | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373958839 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 BODIN CIR FAIRFIELD CA 94533 | ||||||||
| Address2: | DAVID GRANT MEDICAL CENTER | ||||||||
| City: | FPO | ||||||||
| State: | AA | ||||||||
| PostalCode: | 94533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074237300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2017 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34.013591 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.