Provider Demographics
NPI:1710236799
Name:WALTERS, KIMBERLY (DMD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 LANCASTER DR NE, SUITE A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-391-2219
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415
Practice Address - Country:US
Practice Address - Phone:612-873-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10041122300000X
CA618291223G0001X
AZD008447122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice