Healthcare Provider Details

I. General information

NPI: 1538146766
Provider Name (Legal Business Name): REYNALDO DANTES DIZON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOEL DANTES DIZON PA

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE MEDICAL CENTER DR DHMC DEPARTMENT OF ORTHOPAEDICS
LEBANON NH
03756-0001
US

IV. Provider business mailing address

ONE MEDICAL CENTER DR DHMC DEPARTMENT OF ORTHOPAEDICS
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0903
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004702
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2551-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: