Provider Demographics
NPI:1235620097
Name:WALKER, MIRIAM
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 LAMONT CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-4715
Mailing Address - Country:US
Mailing Address - Phone:931-338-7494
Mailing Address - Fax:
Practice Address - Street 1:495 DUNLOP LN STE 112
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5296
Practice Address - Country:US
Practice Address - Phone:931-221-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000113021223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry