Provider Demographics
NPI:1164837621
Name:DIXIE PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:DIXIE PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:KENDALL
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-688-8827
Mailing Address - Street 1:368 E RIVERSIDE DR
Mailing Address - Street 2:BUILDING 6
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6896
Mailing Address - Country:US
Mailing Address - Phone:435-688-8827
Mailing Address - Fax:435-688-8826
Practice Address - Street 1:368 E RIVERSIDE DR
Practice Address - Street 2:BUILDING 6
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6896
Practice Address - Country:US
Practice Address - Phone:435-688-8827
Practice Address - Fax:435-688-8826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53361531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty