Provider Demographics
NPI:1770664021
Name:MIXON, ROBERT N (DMD, PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:N
Last Name:MIXON
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 SW 91ST DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-3028
Mailing Address - Country:US
Mailing Address - Phone:352-335-7777
Mailing Address - Fax:352-371-3430
Practice Address - Street 1:5209 SW 91ST DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-3028
Practice Address - Country:US
Practice Address - Phone:352-335-7777
Practice Address - Fax:352-371-3430
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00140571223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071755000Medicaid
FL36580OtherBLUE CROSS BLUE SHIELD
FL986885OtherUNITED CONCORDIA