Provider Demographics
NPI:1093096331
Name:DALE, JOSH ALAN (RD, LD)
Entity type:Individual
Prefix:
First Name:JOSH
Middle Name:ALAN
Last Name:DALE
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WESTGLEN CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4704
Mailing Address - Country:US
Mailing Address - Phone:636-373-2196
Mailing Address - Fax:
Practice Address - Street 1:3117 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1212
Practice Address - Country:US
Practice Address - Phone:314-652-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006038467133V00000X
IL164004815133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered