Provider Demographics
NPI:1265475784
Name:DALTON, HEATHER DAWN (DC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:DALTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 OCONNOR DR STE 105
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4542
Mailing Address - Country:US
Mailing Address - Phone:262-723-2739
Mailing Address - Fax:
Practice Address - Street 1:210 OCONNOR DR STE 105
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4542
Practice Address - Country:US
Practice Address - Phone:262-723-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4048-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38956300Medicaid
WIV02313Medicare UPIN
WI002170175Medicare ID - Type Unspecified