Provider Demographics
NPI:1376764605
Name:INGRAM, DANIEL WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WALTER
Last Name:INGRAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 LAKE JAMES DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-6779
Mailing Address - Country:US
Mailing Address - Phone:757-420-4214
Mailing Address - Fax:
Practice Address - Street 1:1212 LAKE JAMES DR
Practice Address - Street 2:SUITE A
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-6779
Practice Address - Country:US
Practice Address - Phone:757-420-4214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA05288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist