MEDICARE: MS. WANDA DIXON RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	124Q00000X	DC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1526	OTHER	DC	HYGIENIST

General Provider Information

NPI Number	:	1285628263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WANDA DIXON RDH

Provider Business Mailing Address
First Line	:	807 QUACKENBOS ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-1912
Country	:	US
Telephone Number	:	202-433-2480
Fax Number	:

Provider Business Practice Location Address
First Line	:	166 BUCHANAN ST SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20374
Country	:	US
Telephone Number	:	202-433-2480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	07/08/2007

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