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General NPI Number Information
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NPI Number | 1164652376
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Entity Type | Individual
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Provider Name | JEREMY LANE HIXSON DMD
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Gender | Male
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Dates
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Enumeration Date | 07/22/2009
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Last Update Date | 07/29/2014
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Provider Practice Location Address
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Address Line | 4760 N BUTLER AVE SUITE A
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City | FARMINGTON
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State | NM
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Zip | 87401-0816
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Country | US
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Telephone | 505-325-8858
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Fax |
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Provider Business Mailing Address
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Address Line | 243 N SALINA AVE
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City | EAGLE
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State | ID
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Zip | 83616-6899
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Country | US
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Telephone | 214-693-4290
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DD3993
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License Number State | NM
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