Provider Demographics
NPI:1124012059
Name:DALTON, MICHAEL J (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DALTON
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 1:100 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003-7405
Mailing Address - Country:US
Mailing Address - Phone:563-557-1440
Mailing Address - Fax:563-557-7001
Practice Address - Street 1:100 BRYANT ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-7405
Practice Address - Country:US
Practice Address - Phone:563-557-1440
Practice Address - Fax:563-557-7001
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074401223S0112X
WI41620151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0298877Medicaid
IA29887OtherBCBS-DELTA DENTAL OF IA
WI33695400Medicaid
IA29887Medicare ID - Type Unspecified
IA29887OtherBCBS-DELTA DENTAL OF IA