Provider Demographics
NPI:1063873388
Name:DIXON ORTHODONTIC DENTAL GROUP
Entity type:Organization
Organization Name:DIXON ORTHODONTIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:858-455-9171
Mailing Address - Street 1:5627 OBERLIN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3748
Mailing Address - Country:US
Mailing Address - Phone:858-455-9171
Mailing Address - Fax:
Practice Address - Street 1:5627 OBERLIN DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3748
Practice Address - Country:US
Practice Address - Phone:858-455-9171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335931223X0400X
CA475651223X0400X
CA465651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty