Healthcare Provider Details

I. General information

NPI: 1194809897
Provider Name (Legal Business Name): JOHN DOUGLAS WALTERS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE DENTAL FACULTY PRACTICE ASSOCIATION INC
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE RM 4113 OHIO STATE UNIVERSITY COLLEGE OF DENTISTRY
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-1472
  • Fax:
Mailing address:
  • Phone: 614-292-1169
  • Fax: 614-292-2438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30-017764
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: