Provider Demographics
NPI:1376566026
Name:DALE, GALEN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GALEN
Middle Name:L
Last Name:DALE
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:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:MAHOMET
Mailing Address - State:IL
Mailing Address - Zip Code:61853-0950
Mailing Address - Country:US
Mailing Address - Phone:217-586-4922
Mailing Address - Fax:
Practice Address - Street 1:1504 PATTON DR
Practice Address - Street 2:SUITE #1
Practice Address - City:MAHOMET
Practice Address - State:IL
Practice Address - Zip Code:61853-8113
Practice Address - Country:US
Practice Address - Phone:217-586-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0173761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice