Healthcare Provider Details

I. General information

NPI: 1366524928
Provider Name (Legal Business Name): EARL D WALKER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3036 BRECKENRIDGE LN SUITE 103
LOUISVILLE KY
40220-2196
US

IV. Provider business mailing address

3036 BRECKENRIDGE LN SUITE 103
LOUISVILLE KY
40220-2196
US

V. Phone/Fax

Practice location:
  • Phone: 502-495-1822
  • Fax: 502-495-1825
Mailing address:
  • Phone: 502-495-1822
  • Fax: 502-495-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6102
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: