Provider Demographics
NPI:1194927889
Name:GEORGE J WALTERS DDS PA
Entity type:Organization
Organization Name:GEORGE J WALTERS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-763-8585
Mailing Address - Street 1:2202 STATE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7601
Mailing Address - Country:US
Mailing Address - Phone:850-763-8585
Mailing Address - Fax:850-763-3920
Practice Address - Street 1:2202 STATE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7601
Practice Address - Country:US
Practice Address - Phone:850-763-8585
Practice Address - Fax:850-763-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00124321223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL63954Medicare ID - Type Unspecified
FLU10820Medicare UPIN