Provider Demographics
NPI:1093263618
Name:DIXIE DENTAL CORP
Entity Type:Organization
Organization Name:DIXIE DENTAL CORP
Other - Org Name:DENTAL AMERICAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-512-4589
Mailing Address - Street 1:3408 W 84TH ST STE 317
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4944
Mailing Address - Country:US
Mailing Address - Phone:305-512-4589
Mailing Address - Fax:305-273-9331
Practice Address - Street 1:8718 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3512
Practice Address - Country:US
Practice Address - Phone:305-273-9330
Practice Address - Fax:305-273-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN125931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty