Provider Demographics
NPI:1144555657
Name:DICKSON, CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
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 1:9761 SOUTH COTTAGE GROVE AVE.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1510
Mailing Address - Country:US
Mailing Address - Phone:773-721-7799
Mailing Address - Fax:773-721-3719
Practice Address - Street 1:9761 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-1510
Practice Address - Country:US
Practice Address - Phone:773-721-7799
Practice Address - Fax:773-721-3719
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL031901697511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice