Healthcare Provider Details

I. General information

NPI: 1558688119
Provider Name (Legal Business Name): MICHAEL PATRICK GWALTNEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 AMHERST ST STE L02
WINCHESTER VA
22601-3346
US

IV. Provider business mailing address

1705 AMHERST ST STE L02
WINCHESTER VA
22601-3346
US

V. Phone/Fax

Practice location:
  • Phone: 540-773-3282
  • Fax: 540-773-3284
Mailing address:
  • Phone: 540-773-3282
  • Fax: 540-773-3284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401007868
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: