Provider Demographics
NPI:1801185533
Name:KNUTSON, DALE GRANT
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:GRANT
Last Name:KNUTSON
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 1:1600 N BROWN RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8141
Mailing Address - Country:US
Mailing Address - Phone:678-720-3562
Mailing Address - Fax:
Practice Address - Street 1:1600 N BROWN RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8141
Practice Address - Country:US
Practice Address - Phone:678-720-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA17931208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics