Provider Demographics
NPI:1306129333
Name:JEROMY R. DIXSON, DMD, LLC
Entity type:Organization
Organization Name:JEROMY R. DIXSON, DMD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:FRANCHESCA
Authorized Official - Last Name:HULTGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-577-1440
Mailing Address - Street 1:820 OCEAN BEACH HWY
Mailing Address - Street 2:STE. 110
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4080
Mailing Address - Country:US
Mailing Address - Phone:360-577-1440
Mailing Address - Fax:360-423-3343
Practice Address - Street 1:2225 MISSION ST SE
Practice Address - Street 2:STE. 150
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1297
Practice Address - Country:US
Practice Address - Phone:503-585-1458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty