Provider Demographics
NPI:1902835408
Name:DALLAS, JOHN LAFAYETTE (BSCDCCCSP)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LAFAYETTE
Last Name:DALLAS
Suffix:
Gender:M
Credentials:BSCDCCCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-4330
Mailing Address - Country:US
Mailing Address - Phone:517-882-0251
Mailing Address - Fax:517-882-2724
Practice Address - Street 1:1505 W HOLMES RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-4330
Practice Address - Country:US
Practice Address - Phone:517-882-0251
Practice Address - Fax:517-882-2724
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005663111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU19333Medicare UPIN
MIOC35170Medicare ID - Type Unspecified