Healthcare Provider Details

I. General information

NPI: 1588753511
Provider Name (Legal Business Name): WALTER J DENHAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 E. WHITE MOUNTAIN BLVD. SUITE D
PINETOP AZ
85935
US

IV. Provider business mailing address

PO BOX 2040
PINETOP AZ
85935-2040
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-5111
  • Fax: 928-367-6442
Mailing address:
  • Phone: 928-367-5111
  • Fax: 928-367-6442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3230
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: