Provider Demographics
NPI:1083823306
Name:BLEVINS, WALTER JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:BLEVINS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-1109
Mailing Address - Country:US
Mailing Address - Phone:606-743-1212
Mailing Address - Fax:606-743-1214
Practice Address - Street 1:777 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-1109
Practice Address - Country:US
Practice Address - Phone:606-743-1212
Practice Address - Fax:606-743-1214
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60045622Medicaid