Provider Demographics
NPI:1003463845
Name:TODD DIXON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:TODD DIXON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-583-6613
Mailing Address - Street 1:26 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8879
Mailing Address - Country:US
Mailing Address - Phone:601-583-6613
Mailing Address - Fax:601-583-9832
Practice Address - Street 1:26 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8879
Practice Address - Country:US
Practice Address - Phone:601-583-6613
Practice Address - Fax:601-583-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-26
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660391Medicaid