Healthcare Provider Details

I. General information

NPI: 1164122610
Provider Name (Legal Business Name): MR. KEVIN WALTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 03/03/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SONGTAN BOULEVARD, OSAN AIR BASE UNIT 2060
APO AP
96278-2060
US

IV. Provider business mailing address

PSC 3 BOX 4756
APO AP
96266-0048
US

V. Phone/Fax

Practice location:
  • Phone: 505-784-2108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: