Healthcare Provider Details

I. General information

NPI: 1629726997
Provider Name (Legal Business Name): WALTON COLBY GODWIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13605 REESE BLVD W
HUNTERSVILLE NC
28078-6250
US

IV. Provider business mailing address

13605 REESE BLVD W
HUNTERSVILLE NC
28078-6250
US

V. Phone/Fax

Practice location:
  • Phone: 704-948-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12748
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: