Healthcare Provider Details

I. General information

NPI: 1366498677
Provider Name (Legal Business Name): LINDA MARY DALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 23RD AVE
MERIDIAN MS
39301-4026
US

IV. Provider business mailing address

1516 23RD AVE
MERIDIAN MS
39301-4026
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-3820
  • Fax: 601-703-0125
Mailing address:
  • Phone: 601-703-3820
  • Fax: 601-703-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number200000203
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number30413
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number21644
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: