Provider Demographics
NPI:1710674254
Name:WALTER, BRENDEN (DDS)
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:
Last Name:WALTER
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 1:501 LAPEER AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1203
Mailing Address - Country:US
Mailing Address - Phone:989-720-4188
Mailing Address - Fax:989-921-4959
Practice Address - Street 1:GREAT LAKES BAY HEALTH CENTERS
Practice Address - Street 2:200 N CALEDONIA
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867
Practice Address - Country:US
Practice Address - Phone:989-720-4822
Practice Address - Fax:989-921-4959
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist