Provider Demographics
NPI:1184772303
Name:WALTERS, JERE P (DDS)
Entity type:Individual
Prefix:
First Name:JERE
Middle Name:P
Last Name:WALTERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 S IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-1614
Mailing Address - Country:US
Mailing Address - Phone:406-782-8719
Mailing Address - Fax:
Practice Address - Street 1:238 S IDAHO ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-1614
Practice Address - Country:US
Practice Address - Phone:406-782-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0112801Medicaid
1501839OtherUNITED CONCORDIA
41054OtherBLUE CROSS
MT5512429OtherCHIP