Healthcare Provider Details

I. General information

NPI: 1811005143
Provider Name (Legal Business Name): DALTON SURGICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 BROADRICK DR
DALTON GA
30720
US

IV. Provider business mailing address

PO BOX 1969 1504 BROADRICK DR
DALTON GA
30722-1969
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-6403
  • Fax: 706-278-0087
Mailing address:
  • Phone: 706-278-6403
  • Fax: 706-278-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: WANDA HOLT
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-278-6403