Provider Demographics
NPI:1295760502
Name:WALKER, JOHN S (DMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:WALKER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 BROADWAY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-3300
Mailing Address - Country:US
Mailing Address - Phone:303-494-3535
Mailing Address - Fax:303-494-5095
Practice Address - Street 1:350 BROADWAY
Practice Address - Street 2:SUITE 120
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3300
Practice Address - Country:US
Practice Address - Phone:303-494-3535
Practice Address - Fax:303-494-5095
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHDL053551223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO105355Medicaid