Healthcare Provider Details

I. General information

NPI: 1073510624
Provider Name (Legal Business Name): JENNIFER MARK DIXON D.D.S M.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 CONNOR DR
CHARLOTTESVILLE VA
22911-5604
US

IV. Provider business mailing address

1418 CEDARWOOD CT
CHARLOTTESVILLE VA
22903-7899
US

V. Phone/Fax

Practice location:
  • Phone: 434-975-7336
  • Fax: 434-975-7338
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401410755
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: