Provider Demographics
NPI:1972648574
Name:WALTHER, COREY J (DDS)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:J
Last Name:WALTHER
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 1:2323 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-3448
Mailing Address - Country:US
Mailing Address - Phone:847-426-6520
Mailing Address - Fax:847-426-6528
Practice Address - Street 1:2323 RANDALL RD
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-3448
Practice Address - Country:US
Practice Address - Phone:847-426-6520
Practice Address - Fax:847-426-6528
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice