Provider Demographics
NPI:1063867604
Name:WALKER, ADDISON L (DDM)
Entity Type:Individual
Prefix:MR
First Name:ADDISON
Middle Name:L
Last Name:WALKER
Suffix:
Gender:M
Credentials:DDM
Other - Prefix:
Other - First Name:ADDISON
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12419 CANTRELL RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-1727
Mailing Address - Country:US
Mailing Address - Phone:501-223-8442
Mailing Address - Fax:501-224-2900
Practice Address - Street 1:12419 CANTRELL RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-1727
Practice Address - Country:US
Practice Address - Phone:501-223-8442
Practice Address - Fax:501-224-2900
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC87911223G0001X
390200000X
AR46431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program