Healthcare Provider Details

I. General information

NPI: 1992628929
Provider Name (Legal Business Name): MADELEINE LANE WALTERS DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 E VIRGINIA BEACH BLVD
NORFOLK VA
23502-2530
US

IV. Provider business mailing address

230 E 40TH ST APT D4
NORFOLK VA
23504-1050
US

V. Phone/Fax

Practice location:
  • Phone: 757-244-9734
  • Fax:
Mailing address:
  • Phone: 434-996-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401419929
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: