Healthcare Provider Details

I. General information

NPI: 1750552923
Provider Name (Legal Business Name): DR. WALTER L. STEWART DDS,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 S GREENWOOD ST
LAGRANGE GA
30240-3120
US

IV. Provider business mailing address

208 S GREENWOOD ST
LAGRANGE GA
30240-3120
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-7711
  • Fax: 706-882-7713
Mailing address:
  • Phone: 706-882-7711
  • Fax: 706-882-7713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN007648
License Number StateGA

VIII. Authorized Official

Name: DR. WALTER LORANDAL STEWART
Title or Position: ORTHODONTIST
Credential: DDS, PC
Phone: 706-882-7711