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General NPI Number Information
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NPI Number | 1780722959
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Entity Type | Individual
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Provider Name | WALTER COOPER SANDUSKY III DDS, MS
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Gender | Male
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 6262 POPLAR AVE
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City | MEMPHIS
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State | TN
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Zip | 38119-4728
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Country | US
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Telephone | 901-761-3700
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Fax | 901-680-0403
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Provider Business Mailing Address
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Address Line | 6262 POPLAR AVE
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City | MEMPHIS
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State | TN
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Zip | 38119-4728
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Country | US
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Telephone | 901-761-3700
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Fax | 901-680-0403
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 3809
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License Number State | TN
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