Provider Demographics
NPI:1760568307
Name:DR. TODD W. WALTERS P.C.
Entity Type:Organization
Organization Name:DR. TODD W. WALTERS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT -OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-722-5313
Mailing Address - Street 1:800 FULTON ST STE 4A
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1579
Mailing Address - Country:US
Mailing Address - Phone:574-722-5313
Mailing Address - Fax:574-753-3025
Practice Address - Street 1:800 FULTON ST STE 4A
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1579
Practice Address - Country:US
Practice Address - Phone:574-722-5313
Practice Address - Fax:574-753-3025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120088311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100070910Medicaid