Provider Demographics
NPI:1144409509
Name:MOORHEAD, WALTER LEWIS III (DDS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LEWIS
Last Name:MOORHEAD
Suffix:III
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:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929-1140
Mailing Address - Country:US
Mailing Address - Phone:907-874-3731
Mailing Address - Fax:907-874-3531
Practice Address - Street 1:215 FRONT ST
Practice Address - Street 2:
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929-1140
Practice Address - Country:US
Practice Address - Phone:907-874-3731
Practice Address - Fax:907-874-3531
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0550Medicaid