Provider Demographics
NPI:1033557160
Name:DALTON DERMATOLOGY & DAY SPA, LLC
Entity Type:Organization
Organization Name:DALTON DERMATOLOGY & DAY SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-226-3311
Mailing Address - Street 1:1108 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2588
Mailing Address - Country:US
Mailing Address - Phone:706-226-3311
Mailing Address - Fax:
Practice Address - Street 1:1108 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2588
Practice Address - Country:US
Practice Address - Phone:706-226-3311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065349207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAPENDINGMedicaid