Provider Demographics
NPI:1902237472
Name:DICKERSON, CHESTER (DOM)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5903 ASPEN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5217
Mailing Address - Country:US
Mailing Address - Phone:512-550-8535
Mailing Address - Fax:
Practice Address - Street 1:1350 JACKIE RD SE
Practice Address - Street 2:SUITE 102
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1519
Practice Address - Country:US
Practice Address - Phone:505-896-6965
Practice Address - Fax:505-217-3791
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1106171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist