Provider Demographics
NPI:1003216151
Name:GWALTNEY, JAMES RYLAND
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RYLAND
Last Name:GWALTNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2486 PRUDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4206
Mailing Address - Country:US
Mailing Address - Phone:757-537-4221
Mailing Address - Fax:
Practice Address - Street 1:2486 PRUDEN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4206
Practice Address - Country:US
Practice Address - Phone:757-537-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014145131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice