Provider Demographics
NPI:1629612114
Name:DALTON, JEREMY SCOTT
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:SCOTT
Last Name:DALTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 N 56TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5826
Mailing Address - Country:US
Mailing Address - Phone:218-255-3379
Mailing Address - Fax:
Practice Address - Street 1:2910 W 3RD ST APT 2
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-3327
Practice Address - Country:US
Practice Address - Phone:218-464-4292
Practice Address - Fax:218-464-1186
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND4354378224405172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver