Provider Demographics
NPI:1811005143
Name:DALTON SURGICAL GROUP PC
Entity Type:Organization
Organization Name:DALTON SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-278-6403
Mailing Address - Street 1:PO BOX 1969
Mailing Address - Street 2:1504 BROADRICK DR
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-1969
Mailing Address - Country:US
Mailing Address - Phone:706-278-6403
Mailing Address - Fax:706-278-0087
Practice Address - Street 1:1504 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-278-6403
Practice Address - Fax:706-278-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1781Medicare PIN