Healthcare Provider Details

I. General information

NPI: 1144610361
Provider Name (Legal Business Name): MEGAN A DALUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 PRAIRIE ST
PRAIRIE DU SAC WI
53578-2041
US

IV. Provider business mailing address

1209 MILLS ST PO BOX 383
BLACK EARTH WI
53515-9420
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-8505
  • Fax: 608-643-8097
Mailing address:
  • Phone: 608-767-3604
  • Fax: 608-767-3606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11603-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: