Provider Demographics
NPI:1861512840
Name:CLARK A DIXON DMD PC
Entity type:Organization
Organization Name:CLARK A DIXON DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-937-1411
Mailing Address - Street 1:601 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2232
Mailing Address - Country:US
Mailing Address - Phone:618-937-1411
Mailing Address - Fax:618-937-1911
Practice Address - Street 1:601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2232
Practice Address - Country:US
Practice Address - Phone:618-937-1411
Practice Address - Fax:618-937-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.008005019.0225121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty