Provider Demographics
NPI:1134276827
Name:DALTON, RUSSEL E (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:E
Last Name:DALTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8066 E FLORENTINE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-9422
Mailing Address - Country:US
Mailing Address - Phone:928-772-2474
Mailing Address - Fax:928-772-5838
Practice Address - Street 1:8066 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-9422
Practice Address - Country:US
Practice Address - Phone:928-772-2474
Practice Address - Fax:928-772-5838
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ39481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice