Provider Demographics
NPI:1053322776
Name:DIXON, MICHAEL BENJAMIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:DIXON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828
Mailing Address - Country:US
Mailing Address - Phone:252-753-2218
Mailing Address - Fax:252-753-2218
Practice Address - Street 1:3380 E WILSON ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828
Practice Address - Country:US
Practice Address - Phone:252-753-2218
Practice Address - Fax:252-753-2218
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC92172OtherBCBS
NC7992172Medicaid
NC7992172Medicaid