Provider Demographics
NPI:1891031043
Name:DANIELS, DALLAS MARK (RDH)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:MARK
Last Name:DANIELS
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 A ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-2021
Mailing Address - Country:US
Mailing Address - Phone:970-352-0048
Mailing Address - Fax:970-353-9403
Practice Address - Street 1:2930 11TH AVE
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-1011
Practice Address - Country:US
Practice Address - Phone:970-353-9403
Practice Address - Fax:970-353-9906
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905511124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO905511OtherSTATE LICENSE