Healthcare Provider Details

I. General information

NPI: 1497505424
Provider Name (Legal Business Name): DALTON CUNNINGHAM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 E 81ST ST
TULSA OK
74133-4556
US

IV. Provider business mailing address

1001 N GRAND AVE
TAHLEQUAH OK
74464-7017
US

V. Phone/Fax

Practice location:
  • Phone: 918-250-2020
  • Fax:
Mailing address:
  • Phone: 918-931-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3254
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: