Provider Demographics
NPI:1366719957
Name:CLANTON, DIMA IVONNE (LDO)
Entity type:Individual
Prefix:MRS
First Name:DIMA
Middle Name:IVONNE
Last Name:CLANTON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 GADSEN WALK
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4349
Mailing Address - Country:US
Mailing Address - Phone:678-417-1712
Mailing Address - Fax:
Practice Address - Street 1:4166 BUFORD HWY NE STE S6-T5
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-1081
Practice Address - Country:US
Practice Address - Phone:404-855-3888
Practice Address - Fax:404-855-4388
Is Sole Proprietor?:No
Enumeration Date:2011-11-26
Last Update Date:2011-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002424156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician