Provider Demographics
NPI:1265570873
Name:WALTER, JUSTIN TODD (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:TODD
Last Name:WALTER
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 1:1230 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-5203
Mailing Address - Country:US
Mailing Address - Phone:503-981-3603
Mailing Address - Fax:503-981-3604
Practice Address - Street 1:1230 GEORGE ST
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-5203
Practice Address - Country:US
Practice Address - Phone:503-981-3603
Practice Address - Fax:503-981-3604
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist