Provider Demographics
NPI:1467697094
Name:DALISE, DAVID DOMINIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DOMINIC
Last Name:DALISE
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 1:8500 WAHINGTON ST NE
Mailing Address - Street 2:STE A1
Mailing Address - City:ALBUQURQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113
Mailing Address - Country:US
Mailing Address - Phone:505-293-0025
Mailing Address - Fax:050-293-0447
Practice Address - Street 1:8500 WAHINGTON ST NE
Practice Address - Street 2:STE A1
Practice Address - City:ALBUQURQUE
Practice Address - State:NM
Practice Address - Zip Code:87113
Practice Address - Country:US
Practice Address - Phone:505-293-0025
Practice Address - Fax:050-293-0447
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist