Provider Demographics
NPI:1538224522
Name:NIXON, DALE T (DDS)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:T
Last Name:NIXON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:MANITOWISH WATERS
Mailing Address - State:WI
Mailing Address - Zip Code:54545-0041
Mailing Address - Country:US
Mailing Address - Phone:715-543-2616
Mailing Address - Fax:
Practice Address - Street 1:615 LAKE SHORE DR W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1507
Practice Address - Country:US
Practice Address - Phone:715-682-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3829 015 EWI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33497500Medicaid
WI33497500Medicaid