Provider Demographics
NPI:1023504230
Name:DAVIS, DALTON ALAN
Entity type:Individual
Prefix:
First Name:DALTON
Middle Name:ALAN
Last Name:DAVIS
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 1:2215 VICTORY PKWY APT D5
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2831
Mailing Address - Country:US
Mailing Address - Phone:614-905-9057
Mailing Address - Fax:
Practice Address - Street 1:3800 VICTORY PKWY UNIT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1092
Practice Address - Country:US
Practice Address - Phone:513-745-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer