Provider Demographics
NPI:1245584267
Name:DIXON, ROSELYNN D (EFDA)
Entity Type:Individual
Prefix:MRS
First Name:ROSELYNN
Middle Name:D
Last Name:DIXON
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:MS
Other - First Name:ROSELYNN
Other - Middle Name:D
Other - Last Name:AVECILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EFDA
Mailing Address - Street 1:747 SW 17TH WAY
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-1533
Mailing Address - Country:US
Mailing Address - Phone:503-309-3556
Mailing Address - Fax:
Practice Address - Street 1:1314 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1127
Practice Address - Country:US
Practice Address - Phone:503-280-2877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA0628126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant