Healthcare Provider Details

I. General information

NPI: 1912900648
Provider Name (Legal Business Name): TIMOTHY JOHN DALTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 BETHABARA RD
WINSTON-SALEM NC
27106-3375
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-759-7596
  • Fax: 336-759-3652
Mailing address:
  • Phone: 336-759-7596
  • Fax: 336-759-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9500876
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number95-00876
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number95-00876
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: