Provider Demographics
NPI:1962516211
Name:TICKNER, WALTER F (DDS)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:F
Last Name:TICKNER
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 1:1736 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4803
Mailing Address - Country:US
Mailing Address - Phone:510-351-1400
Mailing Address - Fax:510-351-3116
Practice Address - Street 1:1736 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4803
Practice Address - Country:US
Practice Address - Phone:510-351-1400
Practice Address - Fax:510-351-3116
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23418122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist