Provider Demographics
NPI:1598808032
Name:BACON, DAN EDWARD (RD,LD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:EDWARD
Last Name:BACON
Suffix:
Gender:M
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1715
Mailing Address - Country:US
Mailing Address - Phone:404-294-3762
Mailing Address - Fax:404-508-7752
Practice Address - Street 1:440 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1715
Practice Address - Country:US
Practice Address - Phone:404-294-3762
Practice Address - Fax:404-508-7752
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002312133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered