Provider Demographics
NPI:1891331104
Name:DAWALT, SAMANTHA J (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:J
Last Name:DAWALT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LUXEMBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54217-0236
Mailing Address - Country:US
Mailing Address - Phone:920-845-5654
Mailing Address - Fax:920-845-5640
Practice Address - Street 1:637 MAIN ST
Practice Address - Street 2:
Practice Address - City:LUXEMBURG
Practice Address - State:WI
Practice Address - Zip Code:54217-1125
Practice Address - Country:US
Practice Address - Phone:920-845-5645
Practice Address - Fax:920-845-5640
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5487-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor