Provider Demographics
NPI:1265424907
Name:WALTERS, NATHAN FREDERICK (DMD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:FREDERICK
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 CANNONS LN STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2164
Mailing Address - Country:US
Mailing Address - Phone:502-454-4885
Mailing Address - Fax:502-452-1926
Practice Address - Street 1:2800 CANNONS LN STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2164
Practice Address - Country:US
Practice Address - Phone:502-454-4885
Practice Address - Fax:502-452-1926
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY80661223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200498320Medicaid
KY000000339061OtherBC/BS
KY60002789Medicaid
KY64082688Medicaid
KY60002789Medicaid
KY0906802Medicare PIN