Provider Demographics
NPI:1396820775
Name:DIXON, FREDRICO ALBERT III (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDRICO
Middle Name:ALBERT
Last Name:DIXON
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7218 HIGHWAY 85
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2908
Mailing Address - Country:US
Mailing Address - Phone:404-593-3404
Mailing Address - Fax:404-228-9673
Practice Address - Street 1:7218 HIGHWAY 85
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2908
Practice Address - Country:US
Practice Address - Phone:404-593-3404
Practice Address - Fax:404-228-9673
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0145661223G0001X, 1223G0001X
TNDS72701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510DNOtherBCBS
GA003134944FMedicaid
TN4127424OtherBLUE CROSS/BLUE SHIELD
AL134192Medicaid
TN4127424OtherBLUE CROSS/BLUE SHIELD
AL00510BSOtherBCBS
TN110001OtherTENNCARE LOCATION
TN5440276Medicaid