1356301659 NPI number — MS. MARY DICKERSON LEE DMD

Table of content: MS. MARY DICKERSON LEE DMD (NPI 1356301659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356301659 NPI number — MS. MARY DICKERSON LEE DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON LEE
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356301659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2048
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36652-2048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-432-4117
Provider Business Mailing Address Fax Number:
251-964-4011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 DR MARTIN L KING JR AVE
Provider Second Line Business Practice Location Address:
FRANKLIN PRIMARY HEALTH CENTER INC
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36603-5341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-432-4117
Provider Business Practice Location Address Fax Number:
251-964-4011
Provider Enumeration Date:
03/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  LNO4503 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 51092208 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".