Provider Demographics
NPI:1831667716
Name:DALTON, BRYAN HENRY
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:HENRY
Last Name:DALTON
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 1:4231 ROYAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9789
Mailing Address - Country:US
Mailing Address - Phone:182-786-9082
Mailing Address - Fax:
Practice Address - Street 1:539 CHAMPION RD # 4
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-7706
Practice Address - Country:US
Practice Address - Phone:181-278-6908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN82-2171042OtherTIN