Provider Demographics
NPI:1265719959
Name:WISE, DIXON J (DMD)
Entity type:Individual
Prefix:MR
First Name:DIXON
Middle Name:J
Last Name:WISE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4361
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-4361
Mailing Address - Country:US
Mailing Address - Phone:601-425-3033
Mailing Address - Fax:601-422-0431
Practice Address - Street 1:117 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4312
Practice Address - Country:US
Practice Address - Phone:601-425-3033
Practice Address - Fax:601-422-0431
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10449122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist