Provider Demographics
NPI:1942313408
Name:WALTERS, GREGORY MARK (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MARK
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:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-1270
Mailing Address - Country:US
Mailing Address - Phone:479-524-6443
Mailing Address - Fax:479-524-6440
Practice Address - Street 1:460 S HOLLY
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-1270
Practice Address - Country:US
Practice Address - Phone:479-524-6443
Practice Address - Fax:479-524-6440
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2458AR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice