Provider Demographics
NPI:1295816197
Name:WALTON, ELIZABETH GRACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:GRACE
Last Name:WALTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4849 N MILWAUKEE AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2169
Mailing Address - Country:US
Mailing Address - Phone:773-946-2080
Mailing Address - Fax:
Practice Address - Street 1:1812 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-2039
Practice Address - Country:US
Practice Address - Phone:708-498-4410
Practice Address - Fax:708-499-1044
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-026919122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist