Provider Demographics
NPI:1942298062
Name:WALTERS, JEFFREY MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MARK
Last Name:WALTERS
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 1:881 GARDINER DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7602
Mailing Address - Country:US
Mailing Address - Phone:631-666-6367
Mailing Address - Fax:
Practice Address - Street 1:116 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2797
Practice Address - Country:US
Practice Address - Phone:631-264-2610
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0286431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice