Provider Demographics
NPI:1992843197
Name:WALTHER, NEWELL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:NEWELL
Middle Name:A
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 1:1700 BOGARD RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6533
Mailing Address - Country:US
Mailing Address - Phone:907-376-9449
Mailing Address - Fax:907-376-9339
Practice Address - Street 1:1700 BOGARD RD
Practice Address - Street 2:SUITE 204
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6533
Practice Address - Country:US
Practice Address - Phone:907-376-9449
Practice Address - Fax:907-376-9339
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD29612Medicaid