Active NPI
Derek T Rickson, DDS
- Dentist
- Logan, UT
National Provider Identifier
1508419698
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 11773797-9923
- Practice address
- 1451 N 200 E Ste 200
Logan, UT 84341-7565 - Phone
- (435) 258-9039
- Fax
- (435) 787-1741
- NPI assigned
- Jul 18, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 11773797-9923 | UT | Primary |
Addresses
Primary practice location
1451 N 200 E Ste 200
Logan, UT 84341-7565
Mailing address
542 S 850 E
Smithfield, UT 84335-2549
Phone (435) 764-8618
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11773797-9923 | UT | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1563408000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1593993600000",
"number": "1508419698",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "542 S 850 E",
"city": "SMITHFIELD",
"state": "UT",
"postal_code": "843352549",
"telephone_number": "435-764-8618"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1451 N 200 E STE 200",
"city": "LOGAN",
"state": "UT",
"postal_code": "843417565",
"telephone_number": "435-258-9039",
"fax_number": "435-787-1741"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RICKSON",
"first_name": "DEREK",
"middle_name": "T",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2019-07-18",
"last_updated": "2020-07-06",
"certification_date": "2020-07-06",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "UT",
"license": "11773797-9923",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Logan, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.