Provider Demographics
NPI:1962732073
Name:DALEN, JEFF A (DDS)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:A
Last Name:DALEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4909
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-4909
Mailing Address - Country:US
Mailing Address - Phone:406-862-4301
Mailing Address - Fax:406-862-9347
Practice Address - Street 1:6345 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-8236
Practice Address - Country:US
Practice Address - Phone:406-862-4301
Practice Address - Fax:406-862-9347
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0112217Medicaid