Provider Demographics
NPI:1073837746
Name:WALTHER, RUSSELL (DDS, MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WALTHER
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 CENTENNIAL PL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0572
Mailing Address - Country:US
Mailing Address - Phone:850-523-3000
Mailing Address - Fax:850-523-0831
Practice Address - Street 1:2648 CENTENNIAL PL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0572
Practice Address - Country:US
Practice Address - Phone:850-523-3000
Practice Address - Fax:850-523-0831
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 216511223S0112X
FLME 1264261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery