Healthcare Provider Details

I. General information

NPI: 1497769392
Provider Name (Legal Business Name): W. EDWARD DALTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 N.W. 63RD ST. SUITE 204
OKLAHOMA CITY OK
73116
US

IV. Provider business mailing address

3705 N.W. 63RD ST. SUITE 204
OKLAHOMA CITY OK
73116
US

V. Phone/Fax

Practice location:
  • Phone: 405-842-9732
  • Fax: 405-842-9771
Mailing address:
  • Phone: 405-842-9732
  • Fax: 405-842-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number9436
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: