Provider Demographics
NPI:1639198138
Name:VIDAL, DALE COLLINS (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:COLLINS
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ALICE PECK DAY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2900
Mailing Address - Country:US
Mailing Address - Phone:603-448-3121
Mailing Address - Fax:
Practice Address - Street 1:127 MASCOMA ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-2661
Practice Address - Country:US
Practice Address - Phone:603-443-9572
Practice Address - Fax:603-443-9521
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9412208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30008405Medicaid
VT0RE3751Medicaid
NHRE375102Medicare PIN
G10745Medicare UPIN