Provider Demographics
NPI:1962634857
Name:SMALL, DIXIE LY (LAC, DAOM)
Entity Type:Individual
Prefix:DR
First Name:DIXIE
Middle Name:LY
Last Name:SMALL
Suffix:
Gender:F
Credentials:LAC, DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8931 SE FOSTER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4661
Mailing Address - Country:US
Mailing Address - Phone:503-255-7000
Mailing Address - Fax:503-255-7001
Practice Address - Street 1:8931 SE FOSTER RD
Practice Address - Street 2:STE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4661
Practice Address - Country:US
Practice Address - Phone:503-255-7000
Practice Address - Fax:503-255-7001
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01277171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500653508Medicaid