Provider Demographics
NPI:1821100561
Name:DALTON P COE DDS PC
Entity Type:Organization
Organization Name:DALTON P COE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADI
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOYCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-883-3530
Mailing Address - Street 1:106 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEBEWAING
Mailing Address - State:MI
Mailing Address - Zip Code:48759
Mailing Address - Country:US
Mailing Address - Phone:989-883-3530
Mailing Address - Fax:989-883-9131
Practice Address - Street 1:106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SEBEWAING
Practice Address - State:MI
Practice Address - Zip Code:48759
Practice Address - Country:US
Practice Address - Phone:989-883-3530
Practice Address - Fax:989-883-9131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010177131223G0001X
MI29010195151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty