Provider Demographics
NPI:1154523728
Name:DERRIK WALTON DDS & DARREN J. RUESCH DDS, PC
Entity type:Organization
Organization Name:DERRIK WALTON DDS & DARREN J. RUESCH DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRIK
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-587-2951
Mailing Address - Street 1:1525 BLEISTEIN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3806
Mailing Address - Country:US
Mailing Address - Phone:307-587-2951
Mailing Address - Fax:307-587-2760
Practice Address - Street 1:1525 BLEISTEIN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3806
Practice Address - Country:US
Practice Address - Phone:307-587-2951
Practice Address - Fax:307-587-2760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1008 & 11351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty