Healthcare Provider Details

I. General information

NPI: 1447361381
Provider Name (Legal Business Name): GARY V. DIXON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 SW GRIFFITH DR
BEAVERTON OR
97005-2923
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 503-952-2125
  • Fax: 503-952-2125
Mailing address:
  • Phone: 503-952-2125
  • Fax: 503-952-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number820508017
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10222
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60553642
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD1427
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number64339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: