Provider Demographics
NPI:1508981911
Name:WALZ, LUKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:
Last Name:WALZ
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 1:245 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-0218
Mailing Address - Country:US
Mailing Address - Phone:419-782-7950
Mailing Address - Fax:419-782-8880
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2440
Practice Address - Country:US
Practice Address - Phone:419-782-7950
Practice Address - Fax:419-782-8880
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH218311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1615835OtherUNITED CONCORDIA
OH21831OtherLICSNSE NUMBER
OH2703908Medicaid