Provider Demographics
NPI:1821791526
Name:WALTON-WYNN, QUENTORIA (DMD)
Entity type:Individual
Prefix:
First Name:QUENTORIA
Middle Name:
Last Name:WALTON-WYNN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 GRAYSON AVE
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2973
Mailing Address - Country:US
Mailing Address - Phone:706-442-5323
Mailing Address - Fax:
Practice Address - Street 1:112 VILSECK ROAD
Practice Address - Street 2:BLDG 419
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31315
Practice Address - Country:US
Practice Address - Phone:912-255-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1233141223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program