Provider Demographics
NPI:1447321971
Name:STEWART, WALTER (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:STEWART
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 1:208 SOUTH GREENWOOD ST.
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-882-7711
Mailing Address - Fax:706-882-7713
Practice Address - Street 1:208 S GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3120
Practice Address - Country:US
Practice Address - Phone:706-882-7711
Practice Address - Fax:706-882-7713
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9179576OtherWELLCARE PROVIDER #
GA100747OtherPEACHSTATE PROVIDER #