Provider Demographics
NPI:1134230360
Name:KOHNKE, WALTER S (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:S
Last Name:KOHNKE
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 1:150 TEJAS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:325 POSADA LN STE C
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4003
Practice Address - Country:US
Practice Address - Phone:805-542-6702
Practice Address - Fax:805-542-6796
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA489341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice