Provider Demographics
NPI:1013017136
Name:WALTON, DERRIK PORTER (DDS)
Entity Type:Individual
Prefix:
First Name:DERRIK
Middle Name:PORTER
Last Name:WALTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 BLEISTEIN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3806
Mailing Address - Country:US
Mailing Address - Phone:307-587-2951
Mailing Address - Fax:307-587-2760
Practice Address - Street 1:1525 BLEISTEIN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3806
Practice Address - Country:US
Practice Address - Phone:307-587-2951
Practice Address - Fax:307-587-2760
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice