Provider Demographics
NPI:1285258129
Name:TIPTON, DALLIN JAY (DMD)
Entity type:Individual
Prefix:
First Name:DALLIN
Middle Name:JAY
Last Name:TIPTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2046
Mailing Address - Country:US
Mailing Address - Phone:815-517-0178
Mailing Address - Fax:
Practice Address - Street 1:2235 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2046
Practice Address - Country:US
Practice Address - Phone:815-517-0178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2020-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0325911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice