Provider Demographics
NPI:1356364533
Name:WALTER, JAMES M JR (DDS MS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:WALTER
Suffix:JR
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4012
Mailing Address - Country:US
Mailing Address - Phone:336-768-9881
Mailing Address - Fax:336-768-6066
Practice Address - Street 1:3020 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4012
Practice Address - Country:US
Practice Address - Phone:336-768-9881
Practice Address - Fax:336-768-6066
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC41281223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8998854Medicaid
T63807Medicare UPIN
2427104AMedicare ID - Type Unspecified