Provider Demographics
NPI:1447311329
Name:MICK, WALTER D (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:D
Last Name:MICK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 BRICE RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2701
Mailing Address - Country:US
Mailing Address - Phone:614-864-4618
Mailing Address - Fax:614-860-9225
Practice Address - Street 1:1561 BRICE RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2701
Practice Address - Country:US
Practice Address - Phone:614-864-4618
Practice Address - Fax:614-860-9225
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH185301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice