Provider Demographics
NPI:1912026063
Name:JOHNSON, DIXSON & POND DENTISTRY
Entity Type:Organization
Organization Name:JOHNSON, DIXSON & POND DENTISTRY
Other - Org Name:SMILES FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-577-0566
Mailing Address - Street 1:820 OCEAN BEACH HWY
Mailing Address - Street 2:STE 110
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4080
Mailing Address - Country:US
Mailing Address - Phone:360-577-0566
Mailing Address - Fax:360-425-6935
Practice Address - Street 1:820 OCEAN BEACH HWY,
Practice Address - Street 2:STE 110
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4011
Practice Address - Country:US
Practice Address - Phone:360-577-0566
Practice Address - Fax:360-425-6935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000081751223G0001X
WADE000099421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5046164Medicaid
WA1205926110OtherNPI- PERSONAL