Provider Demographics
NPI:1558574905
Name:MICHAEL S DALTON DDS PA
Entity Type:Organization
Organization Name:MICHAEL S DALTON DDS PA
Other - Org Name:DALTON FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-968-1001
Mailing Address - Street 1:3105 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2454
Mailing Address - Country:US
Mailing Address - Phone:459-968-1001
Mailing Address - Fax:
Practice Address - Street 1:3105 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2454
Practice Address - Country:US
Practice Address - Phone:459-968-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR31171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162329631Medicaid