Ian Robert Dickinson, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D11412 Issued in OR

Practice address

12750 SE Stark St BLDG E
Portland, OR 97233-1539

Phone

(971) 347-3009

Fax

(971) 256-3277

NPI assigned

Feb 12, 2020

Last updated

Dec 13, 2022By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Native American Rehabilitation Assoc Inc

  dba Nara NW

  • Federally Qualified Health Center (FQHC)
  • Portland, OR
  • NPI 1396734364
  Medicare reassignment NPD
• Native American Rehabilitation Assoc Inc

  dba Nara NW-Residential Treatment Center

  • Federally Qualified Health Center (FQHC)
  • Portland, OR
  • NPI 1023007093
  NPD
• Native American Rehabilitation Assoc Inc

  dba Nara NW-Gresham

  • Federally Qualified Health Center (FQHC)
  • Portland, OR
  • NPI 1942747761
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1581465600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1670889600000",
    "number": "1699308130",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "805 SE 74TH AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972152232",
            "telephone_number": "707-280-1901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12750 SE STARK ST BLDG E",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972331539",
            "telephone_number": "971-347-3009",
            "fax_number": "971-256-3277"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DICKINSON",
        "first_name": "IAN",
        "middle_name": "ROBERT",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-02-12",
        "last_updated": "2022-12-13",
        "certification_date": "2022-12-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "CA",
            "license": "DDS104720",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "OR",
            "license": "D11412",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "IDAHO DENTAL LICENSE",
            "identifier": "D-5100",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CALIFORNIA DENTAL LICENSE",
            "identifier": "DDS104720",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Charles Dickerman, LMFT, CADC III, SUDP
• Markus Dickerson
• Sharayah Dickerson
• Sherry M Dickie, M.S. CCC-A
• Valerie Dickie, CADC-R
• Jacki S Dickinson, LMT
• Lisa Anne Dickinson, ND
• Shadey Dickinson
• Emily Marie Dickman
• Alfred Dickson, M.D.

• General Practice Dentistry in Portland, OR
• Providers in Portland, OR by specialty
• General Practice Dentistry in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 13, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.