Provider Demographics
NPI:1922105519
Name:WALTERS, JEFFREY WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:WALTERS
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 1:1585 BERDAN ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-8532
Mailing Address - Country:US
Mailing Address - Phone:715-822-4851
Mailing Address - Fax:715-822-4800
Practice Address - Street 1:1585 BERDAN ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-8532
Practice Address - Country:US
Practice Address - Phone:715-822-4851
Practice Address - Fax:715-822-4800
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4958WI122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33747900Medicare ID - Type Unspecified