Provider Demographics
NPI:1417933896
Name:DIMALANTA, WALTER GOINGCO (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:GOINGCO
Last Name:DIMALANTA
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 1:228 E HOSPITAL RD BLDG 320
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-6011
Mailing Address - Country:US
Mailing Address - Phone:706-787-5530
Mailing Address - Fax:
Practice Address - Street 1:228 E HOSPITAL RD BLDG 320
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099541223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice