Provider Demographics
NPI:1063814838
Name:HIXSON PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:HIXSON PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:D
Authorized Official - Last Name:VICE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:423-842-0165
Mailing Address - Street 1:5470 HIXSON PIKE STE A
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-3299
Mailing Address - Country:US
Mailing Address - Phone:423-842-0165
Mailing Address - Fax:423-842-7614
Practice Address - Street 1:5470 HIXSON PIKE STE A
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-3299
Practice Address - Country:US
Practice Address - Phone:423-842-0165
Practice Address - Fax:423-842-7614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000040551223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033370853OtherPERSONAL NPI
TNDS0000004055OtherDENTAL LICENSE
TNDS0000009112OtherDENTAL LICENSE
GA000338082BMedicaid
GA003126147AMedicaid
TN1528610Medicaid
GA219618537AMedicaid
TN1529061Medicaid
GADN014567OtherDENTAL LICENSE
1548273212OtherPERSONAL NPI
1851382592OtherPERSONAL NPI
TN1527928Medicaid
TNDS0000005135OtherDENTAL LICENSE