Provider Demographics
NPI:1003949827
Name:DIXIE DENTAL
Entity Type:Organization
Organization Name:DIXIE DENTAL
Other - Org Name:DIXIE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST D.D.S.
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PC
Authorized Official - Phone:435-688-1400
Mailing Address - Street 1:425 EAST TABERNACLE
Mailing Address - Street 2:
Mailing Address - City:ST. GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-688-1400
Mailing Address - Fax:435-688-1408
Practice Address - Street 1:425 E TABERNACLE
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-688-1400
Practice Address - Fax:435-688-1408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIXIE DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-13
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9836043799221223G0001X
UT6649422-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
870647649OtherTIN