Provider Demographics
NPI:1023856523
Name:DALTON, GRACE (OD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6947 CRUMPLER BLVD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1922
Mailing Address - Country:US
Mailing Address - Phone:662-893-3300
Mailing Address - Fax:662-893-3301
Practice Address - Street 1:6947 CRUMPLER BLVD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1922
Practice Address - Country:US
Practice Address - Phone:662-893-3300
Practice Address - Fax:662-893-3301
Is Sole Proprietor?:No
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist