Provider Demographics
NPI:1417133661
Name:DIXON DENTAL CARE
Entity Type:Organization
Organization Name:DIXON DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-925-0322
Mailing Address - Street 1:3814 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1528
Mailing Address - Country:US
Mailing Address - Phone:304-925-0322
Mailing Address - Fax:304-925-8426
Practice Address - Street 1:3814 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1528
Practice Address - Country:US
Practice Address - Phone:304-925-0322
Practice Address - Fax:304-925-8426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV23001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010306Medicaid