Provider Demographics
NPI:1790137073
Name:WALKER, JEREMY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 N MERIDIAN RD
Mailing Address - Street 2:STE 101
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634
Mailing Address - Country:US
Mailing Address - Phone:208-274-4444
Mailing Address - Fax:
Practice Address - Street 1:1353 N MERIDIAN RD
Practice Address - Street 2:STE 101
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634
Practice Address - Country:US
Practice Address - Phone:208-274-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1008361223G0001X
IDD-47611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice