Healthcare Provider Details

I. General information

NPI: 1770633075
Provider Name (Legal Business Name): WALTERS FAMILY DENISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3461 WARRENSVILLE CENTER RD STE 301
SHAKER HEIGHTS OH
44122-5227
US

IV. Provider business mailing address

3461 WARRENSVILLE CENTER RD STE 301
SHAKER HEIGHTS OH
44122-5227
US

V. Phone/Fax

Practice location:
  • Phone: 216-382-1102
  • Fax:
Mailing address:
  • Phone: 216-382-1102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number020238
License Number StateOH

VIII. Authorized Official

Name: CYNTHIA TALBERT
Title or Position: CREDENTIALING ANALYST
Credential:
Phone: 330-353-6425