Provider Demographics
NPI:1770679185
Name:WALTER, BENJAMIN H JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:H
Last Name:WALTER
Suffix:JR
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 1:717 CHERRY ST.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4878
Mailing Address - Country:US
Mailing Address - Phone:573-443-7249
Mailing Address - Fax:
Practice Address - Street 1:717 CHERRY ST.
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4878
Practice Address - Country:US
Practice Address - Phone:573-443-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0102691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice