=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205241916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIXON AND DIXON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2014
-----------------------------------------------------
Last Update Date | 06/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 SE 4TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33316-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-523-8788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 SE 4TH AVE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33316-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-523-8788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SCOTT EDWIN DIXON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-523-8788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3742
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------