Provider Demographics
NPI:1538122890
Name:DIXON, DOUGLAS R (DMD, MSD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:DIXON
Suffix:
Gender:M
Credentials:DMD, MSD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 SWIFT ROAD
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1905
Mailing Address - Country:US
Mailing Address - Phone:845-938-4611
Mailing Address - Fax:845-938-4302
Practice Address - Street 1:646 SWIFT ROAD
Practice Address - Street 2:USA DENTAC
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1905
Practice Address - Country:US
Practice Address - Phone:845-938-4611
Practice Address - Fax:845-938-4302
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0021681223P0300X
WI6074-0151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics