Provider Demographics
NPI:1538374822
Name:DANIEL, DARRYL DALE I (DMD)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:DALE
Last Name:DANIEL
Suffix:I
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 1:11 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3773
Mailing Address - Country:US
Mailing Address - Phone:912-261-2999
Mailing Address - Fax:912-261-8368
Practice Address - Street 1:11 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3773
Practice Address - Country:US
Practice Address - Phone:912-261-2999
Practice Address - Fax:912-261-8368
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA109491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice