Provider Demographics
NPI:1669623104
Name:WALTERS, DANIEL CLAYBOURN JR (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:CLAYBOURN
Last Name:WALTERS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 FARRINGDOM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2615
Mailing Address - Country:US
Mailing Address - Phone:910-671-4601
Mailing Address - Fax:
Practice Address - Street 1:580 FARRINGDOM ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2615
Practice Address - Country:US
Practice Address - Phone:910-671-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909749Medicaid