Provider Demographics
NPI:1154310373
Name:WALKER, JERRY H (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:H
Last Name:WALKER
Suffix:
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 1:390 SOUTH 3RD WEST
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276
Mailing Address - Country:US
Mailing Address - Phone:208-547-2220
Mailing Address - Fax:208-547-2224
Practice Address - Street 1:390 SOUTH 3RD WEST
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276
Practice Address - Country:US
Practice Address - Phone:208-547-2220
Practice Address - Fax:208-547-2224
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-38391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807893200Medicaid