Provider Demographics
NPI:1851934160
Name:WALTON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:WALTON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LACOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-367-5191
Mailing Address - Street 1:862 MICHAEL ETCHISON RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-8204
Mailing Address - Country:US
Mailing Address - Phone:770-267-2301
Mailing Address - Fax:770-267-8981
Practice Address - Street 1:862 MICHAEL ETCHISON RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-8204
Practice Address - Country:US
Practice Address - Phone:770-267-2301
Practice Address - Fax:770-267-8981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty