MEDICARE: CHARLES WALTER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	5632	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093883779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES WALTER DDS

Provider Business Mailing Address
First Line	:	3400 SQUALICUM PKWY
Second Line	:	SUITE 102
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-1933
Country	:	US
Telephone Number	:	360-676-8920
Fax Number	:	360-676-5988

Provider Business Practice Location Address
First Line	:	3400 SQUALICUM PKWY
Second Line	:	SUITE 102
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-1933
Country	:	US
Telephone Number	:	360-676-8920
Fax Number	:	360-676-5988

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/09/2007

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