Healthcare Provider Details

I. General information

NPI: 1407844509
Provider Name (Legal Business Name): MARTIN LUTHER WALTON III D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N 11TH ST PED. DENT. VCU SCHOOL OF DENTISTRY
RICHMOND VA
23298-5045
US

IV. Provider business mailing address

PO BOX 980566 PED. DENT. VCU SCHOOL OF DENTISTRY
RICHMOND VA
23298-0566
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-0791
  • Fax: 804-827-0163
Mailing address:
  • Phone: 804-828-0791
  • Fax: 804-827-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401008399
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: