Provider Demographics
NPI:1114653383
Name:MITCHELL, DALLAS BENJAMIN (DC)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:BENJAMIN
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 SHORT ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4343
Mailing Address - Country:US
Mailing Address - Phone:810-824-0693
Mailing Address - Fax:
Practice Address - Street 1:1600 GRATIOT BLVD STE 6
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1145
Practice Address - Country:US
Practice Address - Phone:810-637-1205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2531401182111N00000X
MI2301401317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor