Healthcare Provider Details

I. General information

NPI: 1093782138
Provider Name (Legal Business Name): MARK DALTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

PO BOX 12
LIBERTY LAKE WA
99019-0012
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-7271
  • Fax: 406-327-1834
Mailing address:
  • Phone: 866-747-2455
  • Fax: 406-329-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberO0822
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMED-PHYS-LIC-34175
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: