Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NI0013X | Independent Medical Examiner | 4557 | SC |
NPI | 1295323004 |
---|---|
Provider Name | Dalton Detty |
First Address | Beaufort, SC 29902-6128 |
Second Address | Beaufort, SC 29902-6128 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/01/2021 |
Last Update Date | 07/01/2021 |