Provider Demographics
NPI:1124070222
Name:JAMES M. WALTER, JR, DDS, MS, PA
Entity type:Organization
Organization Name:JAMES M. WALTER, JR, DDS, MS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:336-768-9881
Mailing Address - Street 1:3020 MAPLEWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-768-9881
Mailing Address - Fax:336-768-6066
Practice Address - Street 1:3020 MAPLEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-9881
Practice Address - Fax:336-768-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223P0106X
NC70361223S0112X
NC41281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890191NMedicaid
NC890191NMedicaid