Healthcare Provider Details

I. General information

NPI: 1164652376
Provider Name (Legal Business Name): JEREMY LANE HIXSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 N BUTLER AVE SUITE A
FARMINGTON NM
87401-0816
US

IV. Provider business mailing address

243 N SALINA AVE
EAGLE ID
83616-6899
US

V. Phone/Fax

Practice location:
  • Phone: 505-325-8858
  • Fax:
Mailing address:
  • Phone: 214-693-4290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD3993
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: