Provider Demographics
NPI:1699747378
Name:PEDIATRIC AND ADOLESCENT DENTISTRY
Entity type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LOWELL
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-387-4784
Mailing Address - Street 1:212 STAR ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4825
Mailing Address - Country:US
Mailing Address - Phone:507-387-4784
Mailing Address - Fax:507-387-4078
Practice Address - Street 1:212 STAR ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4825
Practice Address - Country:US
Practice Address - Phone:507-387-4784
Practice Address - Fax:507-387-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty