Provider Demographics
NPI:1396167425
Name:DALLAS, MATTHEW (RD, LDN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DALLAS
Suffix:
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W TRYON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-2438
Mailing Address - Country:US
Mailing Address - Phone:919-245-2400
Mailing Address - Fax:919-644-3007
Practice Address - Street 1:300 W TRYON ST
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-2438
Practice Address - Country:US
Practice Address - Phone:919-245-2400
Practice Address - Fax:919-644-3007
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004309133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered