Provider Demographics
NPI:1396813895
Name:WALTERS, WADE CODY (DDS)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:CODY
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 1:2300 N 14TH STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801
Mailing Address - Country:US
Mailing Address - Phone:620-225-2650
Mailing Address - Fax:620-225-7722
Practice Address - Street 1:2300 N 14TH STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801
Practice Address - Country:US
Practice Address - Phone:620-225-2650
Practice Address - Fax:620-225-7722
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS70081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS59642OtherBC & BS OF KANSAS
KS1417934OtherUNITED CONCORDIA