Provider Demographics
NPI:1295854768
Name:WALTERS, BRUCE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:L
Last Name:WALTERS
Suffix:
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 1:5740 W GRANDE MARKET DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8406
Mailing Address - Country:US
Mailing Address - Phone:920-735-9950
Mailing Address - Fax:920-735-9953
Practice Address - Street 1:5740 W GRANDE MARKET DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8406
Practice Address - Country:US
Practice Address - Phone:920-735-9950
Practice Address - Fax:920-735-9953
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice