MEDICARE: DR. CAMPBELL WALTERS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019.031733	IL
2	122300000X	Dentist	2016025042	MO

General Provider Information

NPI Number	:	1891249652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAMPBELL WALTERS DMD

Provider Business Mailing Address
First Line	:	4337 BUTLER HILL RD STE L
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3735
Country	:	US
Telephone Number	:	314-732-4591
Fax Number	:	314-200-9691

Provider Business Practice Location Address
First Line	:	2380 N TRUMAN BLVD
Second Line	:
City	:	CRYSTAL CITY
State	:	MO
Zip	:	63019-1037
Country	:	US
Telephone Number	:	636-937-9193
Fax Number	:	314-200-9691

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2016
Last Update Date	:	12/19/2018

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