Provider Demographics
NPI:1578636775
Name:WALTON, GARY VINCENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:VINCENT
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 1:9002 N MERIDIAN STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:INDPLS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-574-1138
Mailing Address - Fax:317-574-1302
Practice Address - Street 1:9002 N MERIDIAN STREET
Practice Address - Street 2:SUITE 206
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5381
Practice Address - Country:US
Practice Address - Phone:317-574-1138
Practice Address - Fax:317-574-1302
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7909122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist