Provider Demographics
NPI:1871614198
Name:WALTERS, DENNIS J
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:WALTERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S BROAD ST
Mailing Address - Street 2:P.O. BOX 43
Mailing Address - City:LANARK
Mailing Address - State:IL
Mailing Address - Zip Code:61046-1204
Mailing Address - Country:US
Mailing Address - Phone:815-493-2244
Mailing Address - Fax:815-493-2922
Practice Address - Street 1:120 S BROAD ST
Practice Address - Street 2:
Practice Address - City:LANARK
Practice Address - State:IL
Practice Address - Zip Code:61046-1204
Practice Address - Country:US
Practice Address - Phone:815-493-2244
Practice Address - Fax:815-493-2922
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice