Provider Demographics
NPI:1669602777
Name:DIXON, BREN (DMD)
Entity type:Individual
Prefix:DR
First Name:BREN
Middle Name:
Last Name:DIXON
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 1:1150 CRATER LAKE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6213
Mailing Address - Country:US
Mailing Address - Phone:541-773-3327
Mailing Address - Fax:
Practice Address - Street 1:1150 CRATER LAKE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6213
Practice Address - Country:US
Practice Address - Phone:541-773-3327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2013-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL745122300000X
UT7983955-9923122300000X
ORD97391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist