Provider Demographics
NPI:1558754499
Name:WALTER, RYAN WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:WILLIAM
Last Name:WALTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 GROVER ST
Mailing Address - Street 2:
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1010
Mailing Address - Country:US
Mailing Address - Phone:973-584-1193
Mailing Address - Fax:
Practice Address - Street 1:5 GROVER ST
Practice Address - Street 2:
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1010
Practice Address - Country:US
Practice Address - Phone:973-584-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025865001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics