Provider Demographics
NPI:1407844509
Name:WALTON, MARTIN LUTHER III (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LUTHER
Last Name:WALTON
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 980566
Mailing Address - Street 2:PED. DENT. VCU SCHOOL OF DENTISTRY
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-0566
Mailing Address - Country:US
Mailing Address - Phone:804-828-0791
Mailing Address - Fax:804-827-0163
Practice Address - Street 1:521 N 11TH ST
Practice Address - Street 2:PED. DENT. VCU SCHOOL OF DENTISTRY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5045
Practice Address - Country:US
Practice Address - Phone:804-828-0791
Practice Address - Fax:804-827-0163
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010083991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0007101OtherDORAL
VA78-0361-3Medicaid