Healthcare Provider Details

I. General information

NPI: 1184637829
Provider Name (Legal Business Name): MATTHEW LYONS DALTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 PINECREST RD
NORTH STONINGTON CT
06359-1527
US

IV. Provider business mailing address

NUMI BOX 159 SUBASE NEW LONDON
GROTON CT
06349
US

V. Phone/Fax

Practice location:
  • Phone: 860-535-2004
  • Fax:
Mailing address:
  • Phone: 860-694-2876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: