Healthcare Provider Details

I. General information

NPI: 1932365137
Provider Name (Legal Business Name): KELLY JO DALTON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 BALTIMORE DRIVE
WILKES BARRE PA
18702
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-808-5441
  • Fax: 570-808-5371
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002107
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: