Healthcare Provider Details

I. General information

NPI: 1508980848
Provider Name (Legal Business Name): DIXIE ORAL, MAXILLOFACIAL & IMPLANT SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 DIAGONAL ST SUITE 204
ST GEORGE UT
84770-2878
US

IV. Provider business mailing address

10 DIAGONAL ST SUITE 204
ST GEORGE UT
84770-2878
US

V. Phone/Fax

Practice location:
  • Phone: 435-673-1554
  • Fax: 435-674-9967
Mailing address:
  • Phone: 435-673-1554
  • Fax: 435-674-9967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JOHN HIDEO MIZUKAWA
Title or Position: ORAL SURGEON
Credential: D.D.S.
Phone: 435-673-1554