Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 5101025349 | MI |
NPI | 1003301557 |
---|---|
Provider Name | Dr. Mackenzie Dickinson |
First Address | Lansing, MI 48911-4271 |
Second Address | Lansing, MI 48911-4271 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2018 |
Last Update Date | 01/07/2021 |