Provider Demographics
NPI:1598766123
Name:WALGAST, JOHN M (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:WALGAST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 KEN PRATT BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6419
Mailing Address - Country:US
Mailing Address - Phone:303-651-2700
Mailing Address - Fax:
Practice Address - Street 1:641 KEN PRATT BLVD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6419
Practice Address - Country:US
Practice Address - Phone:303-651-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice