Provider Demographics
NPI:1780229880
Name:DALLAS, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19319 STAHELIN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2713
Mailing Address - Country:US
Mailing Address - Phone:810-986-1723
Mailing Address - Fax:
Practice Address - Street 1:59 SEWARD ST APT 603
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2431
Practice Address - Country:US
Practice Address - Phone:313-773-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor