Healthcare Provider Details

I. General information

NPI: 1124070222
Provider Name (Legal Business Name): JAMES M. WALTER, JR, DDS, MS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 MAPLEWOOD AVENUE
WINSTON SALEM NC
27103
US

IV. Provider business mailing address

3020 MAPLEWOOD AVENUE
WINSTON SALEM NC
27103
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-9881
  • Fax: 336-768-6066
Mailing address:
  • Phone: 336-768-9881
  • Fax: 336-768-6066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7036
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4128
License Number StateNC

VIII. Authorized Official

Name: DR. JAMES M WALTER JR.
Title or Position: OWNER
Credential: DDS MS
Phone: 336-768-9881