Basic Information
Provider Information
NPI: 1629507884
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WALTON
FirstName: SAMUEL
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4871 W DAYBREAK PKWY
Address2:  
City: SOUTH JORDAN
State: UT
PostalCode: 840094818
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3600 E MCKINNEY ST STE 190
Address2:  
City: DENTON
State: TX
PostalCode: 762096543
CountryCode: US
TelephoneNumber: 9403872442
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/09/2017
LastUpdateDate: 06/09/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X33031TXY Dental ProvidersDentistGeneral Practice

No ID Information.


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