Provider Demographics
NPI:1871915496
Name:JOHN S WALKERDMD PROF LLC
Entity type:Organization
Organization Name:JOHN S WALKERDMD PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:GALITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-494-3535
Mailing Address - Street 1:350 BROADWAY ST STE 120
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3300
Mailing Address - Country:US
Mailing Address - Phone:303-494-3535
Mailing Address - Fax:303-494-5095
Practice Address - Street 1:350 BROADWAY ST STE 120
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3300
Practice Address - Country:US
Practice Address - Phone:303-494-3535
Practice Address - Fax:303-494-5095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1053551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2053551Medicaid