Healthcare Provider Details

I. General information

NPI: 1821100561
Provider Name (Legal Business Name): DALTON P COE DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E MAIN ST
SEBEWAING MI
48759
US

IV. Provider business mailing address

106 E MAIN ST
SEBEWAING MI
48759
US

V. Phone/Fax

Practice location:
  • Phone: 989-883-3530
  • Fax: 989-883-9131
Mailing address:
  • Phone: 989-883-3530
  • Fax: 989-883-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019515
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901017713
License Number StateMI

VIII. Authorized Official

Name: BRADI K BOYCE
Title or Position: PRESIDENT
Credential: DDS
Phone: 989-883-3530