=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760593024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL EVAN DIXON D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 YEARICK ST
-----------------------------------------------------
City | ARGOS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46501-1036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-892-5513
-----------------------------------------------------
Fax | 574-892-5279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 LAKE AVE
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46563-2450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-952-0674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12009813
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------