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General NPI Number Information
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NPI Number | 1851934160
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Entity Type | Organization
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Legal Business Name | WALTON FAMILY DENTISTRY LLC
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Dates
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Enumeration Date | 10/21/2019
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Last Update Date | 10/21/2019
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Provider Practice Location Address
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Address Line | 862 MICHAEL ETCHISON RD
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City | MONROE
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State | GA
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Zip | 30655-8204
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Country | US
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Telephone | 770-267-2301
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Fax | 770-267-8981
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Provider Business Mailing Address
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Address Line | 862 MICHAEL ETCHISON RD
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City | MONROE
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State | GA
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Zip | 30655-8204
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Country | US
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Telephone | 770-267-2301
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Fax | 770-267-8981
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Authorized Official
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Title or Position | OWNER
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Name | KEVIN M LACOUR
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Credential | DDS
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Telephone | 770-367-5191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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