Provider Demographics
NPI:1700335346
Name:DALSBO, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DALSBO
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:W13930 OAK HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9280
Mailing Address - Country:US
Mailing Address - Phone:920-748-2557
Mailing Address - Fax:
Practice Address - Street 1:W13930 OAK HAVEN DR
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-9280
Practice Address - Country:US
Practice Address - Phone:920-748-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist