1063814838 NPI number — HIXSON PEDIATRIC DENTISTRY PLLC

Table of content: (NPI 1063814838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063814838 NPI number — HIXSON PEDIATRIC DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIXSON PEDIATRIC DENTISTRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063814838
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5470 HIXSON PIKE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIXSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37343-3299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-842-0165
Provider Business Mailing Address Fax Number:
423-842-7614

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5470 HIXSON PIKE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIXSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37343-3299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-842-0165
Provider Business Practice Location Address Fax Number:
423-842-7614
Provider Enumeration Date:
09/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
VICE
Authorized Official First Name:
HUGH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SENIOR PARTNER
Authorized Official Telephone Number:
423-842-0165

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  DS0000004055 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033370853 . This is a "PERSONAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: DS0000004055 . This is a "DENTAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: DS0000009112 . This is a "DENTAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000338082B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003126147A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1528610 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 219618537A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1529061 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN014567 . This is a "DENTAL LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1548273212 . This is a "PERSONAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1851382592 . This is a "PERSONAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1527928 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DS0000005135 . This is a "DENTAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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