Provider Demographics
NPI:1942476015
Name:WALTHER DENTAL INC
Entity Type:Organization
Organization Name:WALTHER DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NEWELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-376-9449
Mailing Address - Street 1:1700 E BOGARD RD STE B204
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6570
Mailing Address - Country:US
Mailing Address - Phone:907-376-9449
Mailing Address - Fax:907-376-9339
Practice Address - Street 1:1700 E BOGARD RD BLDG B
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6563
Practice Address - Country:US
Practice Address - Phone:907-376-9449
Practice Address - Fax:907-376-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1038122300000X
AK1566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1612641Medicaid
AK1003444Medicaid