Provider Demographics
NPI:1164652376
Name:HIXSON, JEREMY LANE (DMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LANE
Last Name:HIXSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 N SALINA AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6899
Mailing Address - Country:US
Mailing Address - Phone:214-693-4290
Mailing Address - Fax:
Practice Address - Street 1:4760 N BUTLER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-0816
Practice Address - Country:US
Practice Address - Phone:505-325-8858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD39931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery