Provider Demographics
NPI:1629100011
Name:DALE W MUTH OD PLLC
Entity Type:Organization
Organization Name:DALE W MUTH OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:W
Authorized Official - Last Name:MUTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-293-9276
Mailing Address - Street 1:504 W HARRIE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1200
Mailing Address - Country:US
Mailing Address - Phone:906-293-9276
Mailing Address - Fax:906-293-9100
Practice Address - Street 1:504 W HARRIE ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1200
Practice Address - Country:US
Practice Address - Phone:906-293-9276
Practice Address - Fax:906-293-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003944332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4597650001Medicare NSC