Provider Demographics
NPI:1659482206
Name:SHAWN R WALTON
Entity Type:Organization
Organization Name:SHAWN R WALTON
Other - Org Name:WALTON DENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:712-255-7607
Mailing Address - Street 1:2928 HAMILTON BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104
Mailing Address - Country:US
Mailing Address - Phone:712-255-7607
Mailing Address - Fax:712-255-4507
Practice Address - Street 1:2928 HAMILTON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-255-7607
Practice Address - Fax:712-255-4507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07610122300000X
IA08441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025415600Medicaid
IA0102343Medicaid