Provider Demographics
NPI:1184727505
Name:WALTERS, PAUL J (DDS)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
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 1:4420 CONLIN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:METAIRIE
Mailing Address - State:CA
Mailing Address - Zip Code:70006
Mailing Address - Country:US
Mailing Address - Phone:504-455-9960
Mailing Address - Fax:504-455-9961
Practice Address - Street 1:4420 CONLIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:METAIRIE
Practice Address - State:CA
Practice Address - Zip Code:70006
Practice Address - Country:US
Practice Address - Phone:504-455-9960
Practice Address - Fax:504-455-9961
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1822337Medicaid
58317Medicare ID - Type Unspecified
T69602Medicare UPIN