Provider Demographics
NPI:1134207210
Name:DALLAS, DALE C (MD)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:C
Last Name:DALLAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DALE
Other - Middle Name:C
Other - Last Name:LAKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6265 HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-3909
Mailing Address - Country:US
Mailing Address - Phone:831-239-9913
Mailing Address - Fax:888-424-0191
Practice Address - Street 1:6265 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:CA
Practice Address - Zip Code:95018-3909
Practice Address - Country:US
Practice Address - Phone:831-239-9913
Practice Address - Fax:888-424-0191
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG375402084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G375400Medicaid
CA00G375400Medicaid
F27775Medicare UPIN