Provider Demographics
NPI:1154816338
Name:WALTERS, RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WALTERS
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 1:225 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-1126
Mailing Address - Country:US
Mailing Address - Phone:609-405-9011
Mailing Address - Fax:
Practice Address - Street 1:850 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7444
Practice Address - Country:US
Practice Address - Phone:609-405-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO41795122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist