Individual
DR. IAN ROBERT DICKINSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
12750 SE STARK ST BLDG E, PORTLAND, OR 97233-1539
(971) 347-3009
(971) 256-3277
Mailing address
805 SE 74TH AVE, PORTLAND, OR 97215-2232
(707) 280-1901
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D11412
OR
1223G0001X
General Practice Dentistry
DDS104720
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
D-5100
IDAHO DENTAL LICENSE
ID
01
—
DDS104720
CALIFORNIA DENTAL LICENSE
CA
Enumeration date
02/12/2020
Last updated
12/13/2022
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