Provider Demographics
NPI:1891249652
Name:WALTERS, CAMPBELL (DMD)
Entity type:Individual
Prefix:DR
First Name:CAMPBELL
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 BUTLER HILL RD STE L
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3735
Mailing Address - Country:US
Mailing Address - Phone:314-732-4591
Mailing Address - Fax:314-200-9691
Practice Address - Street 1:2380 N TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1037
Practice Address - Country:US
Practice Address - Phone:636-937-9193
Practice Address - Fax:314-200-9691
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031733122300000X
MO2016025042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist