Provider Demographics
NPI:1417090051
Name:DIXON, MELISSA A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:A
Last Name:DIXON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ELM ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4054
Mailing Address - Country:US
Mailing Address - Phone:208-524-2771
Mailing Address - Fax:208-529-4277
Practice Address - Street 1:205 ELM ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4054
Practice Address - Country:US
Practice Address - Phone:208-524-2771
Practice Address - Fax:208-529-4277
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-20551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice