Provider Demographics
NPI:1184637829
Name:DALTON, MATTHEW LYONS
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LYONS
Last Name:DALTON
Suffix:
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:NUMI BOX 159 SUBASE NEW LONDON
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349
Mailing Address - Country:US
Mailing Address - Phone:860-694-2876
Mailing Address - Fax:
Practice Address - Street 1:33 PINECREST RD
Practice Address - Street 2:
Practice Address - City:NORTH STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06359-1527
Practice Address - Country:US
Practice Address - Phone:860-535-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman