Healthcare Provider Details

I. General information

NPI: 1891021432
Provider Name (Legal Business Name): KELLY LYNNE WALTERS D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2009
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1557 ROUTE 82 STE 5
HOPEWELL JUNCTION NY
12533-3328
US

IV. Provider business mailing address

49 ROMBOUT RD
POUGHKEEPSIE NY
12603-6216
US

V. Phone/Fax

Practice location:
  • Phone: 845-896-8880
  • Fax: 845-896-2439
Mailing address:
  • Phone: 845-249-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number50054467
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: