MEDICARE: DR. JUSTIN TODD WALTER D.M.D.

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	122300000X	Dentist	D8760	OR

General Provider Information

NPI Number	:	1265570873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN TODD WALTER D.M.D.

Provider Business Mailing Address
First Line	:	1230 GEORGE ST
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071-5203
Country	:	US
Telephone Number	:	503-981-3603
Fax Number	:	503-981-3604

Provider Business Practice Location Address
First Line	:	1230 GEORGE ST
Second Line	:
City	:	WOODBURN
State	:	OR
Zip	:	97071-5203
Country	:	US
Telephone Number	:	503-981-3603
Fax Number	:	503-981-3604

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

Provider Enumeration Date	:	02/03/2007
Last Update Date	:	10/08/2021

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