Provider Demographics
NPI:1386741718
Name:WALTERS, DAVID P (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:WALTERS
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 1:123 N MCCREARY ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRANCH
Mailing Address - State:IN
Mailing Address - Zip Code:47648-1313
Mailing Address - Country:US
Mailing Address - Phone:812-753-1039
Mailing Address - Fax:812-753-1039
Practice Address - Street 1:123 N MCCREARY ST
Practice Address - Street 2:
Practice Address - City:FORT BRANCH
Practice Address - State:IN
Practice Address - Zip Code:47648-1313
Practice Address - Country:US
Practice Address - Phone:812-753-1039
Practice Address - Fax:812-385-5473
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006998122300000X
IN12006998B1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100122070Medicaid