Provider Demographics
NPI:1093020778
Name:JEROMY R. DIXSON, D.M.D., P.S.
Entity Type:Organization
Organization Name:JEROMY R. DIXSON, D.M.D., P.S.
Other - Org Name:SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:FRANCHESCA
Authorized Official - Last Name:HULTGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-577-1440
Mailing Address - Street 1:820 OCEAN BEACH HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4080
Mailing Address - Country:US
Mailing Address - Phone:360-577-0566
Mailing Address - Fax:360-423-3343
Practice Address - Street 1:820 OCEAN BEACH HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4080
Practice Address - Country:US
Practice Address - Phone:360-577-0566
Practice Address - Fax:360-423-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7293641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty