Provider Demographics
NPI:1437274891
Name:RANDY P WALTERS, DMD, PC
Entity Type:Organization
Organization Name:RANDY P WALTERS, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:334-636-2713
Mailing Address - Street 1:632 W FRONT ST N
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-5316
Mailing Address - Country:US
Mailing Address - Phone:334-636-2713
Mailing Address - Fax:
Practice Address - Street 1:632 W FRONT ST N
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-5316
Practice Address - Country:US
Practice Address - Phone:334-636-2713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL4981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU94105Medicare ID - Type Unspecified