Provider Demographics
NPI:1962664383
Name:DIXON DENTAL CENTER
Entity Type:Organization
Organization Name:DIXON DENTAL CENTER
Other - Org Name:LORIN E. DIXON, D.M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-524-2771
Mailing Address - Street 1:205 ELM ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4054
Mailing Address - Country:US
Mailing Address - Phone:208-524-2771
Mailing Address - Fax:208-529-4277
Practice Address - Street 1:205 ELM ST
Practice Address - Street 2:SUITE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4054
Practice Address - Country:US
Practice Address - Phone:208-524-2771
Practice Address - Fax:208-529-4277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001216200Medicaid