Provider Demographics
NPI:1902264492
Name:DIXON, TY-RE LAMONT SR
Entity Type:Individual
Prefix:MR
First Name:TY-RE
Middle Name:LAMONT
Last Name:DIXON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SHORELINE DR.
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215
Mailing Address - Country:US
Mailing Address - Phone:404-661-1800
Mailing Address - Fax:770-897-3777
Practice Address - Street 1:220 SHORELINE DR.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215
Practice Address - Country:US
Practice Address - Phone:404-661-1800
Practice Address - Fax:770-897-3777
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment