Provider Demographics
NPI:1508912742
Name:WALTERS, KELLY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
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 1:1424 LIVE OAK BLVD
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-2910
Mailing Address - Country:US
Mailing Address - Phone:530-751-1080
Mailing Address - Fax:530-751-1082
Practice Address - Street 1:1424 LIVE OAK BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-2910
Practice Address - Country:US
Practice Address - Phone:530-751-1080
Practice Address - Fax:530-751-1082
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA267971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice