Healthcare Provider Details

I. General information

NPI: 1639146194
Provider Name (Legal Business Name): DANIEL DILLINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 ELECTRIC AVE
PORT HURON MI
48060-6587
US

IV. Provider business mailing address

18275 PRATT RD
ARMADA MI
48005-1153
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-1580
  • Fax:
Mailing address:
  • Phone: 586-784-8207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002794
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: