Provider Demographics
NPI:1619290129
Name:WALKER DENTAL
Entity Type:Organization
Organization Name:WALKER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-977-2551
Mailing Address - Street 1:13660 N 94TH DR
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4836
Mailing Address - Country:US
Mailing Address - Phone:623-977-2551
Mailing Address - Fax:623-977-9590
Practice Address - Street 1:13660 N 94TH DR
Practice Address - Street 2:SUITE B-1
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4836
Practice Address - Country:US
Practice Address - Phone:623-977-2551
Practice Address - Fax:623-977-9590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6996122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ495439Medicaid