Provider Demographics
NPI:1346952405
Name:THORNTON, DALLAS MITCHELL (CPHT)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:MITCHELL
Last Name:THORNTON
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 11TH LN # 288
Mailing Address - Street 2:
Mailing Address - City:FOX ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98333-9661
Mailing Address - Country:US
Mailing Address - Phone:253-549-2350
Mailing Address - Fax:
Practice Address - Street 1:4818 POINT FOSDICK DR
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1711
Practice Address - Country:US
Practice Address - Phone:253-851-6939
Practice Address - Fax:253-858-3203
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60898633374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVA60898633OtherWASHINGTON STATE DEPARTMENT OF HEALTH