Provider Demographics
NPI:1700916913
Name:MYRICK, WALTER MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:MICHAEL
Last Name:MYRICK
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 1:100 FOUNTAIN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-2771
Mailing Address - Country:US
Mailing Address - Phone:270-443-6490
Mailing Address - Fax:270-442-8899
Practice Address - Street 1:100 FOUNTAIN AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-2771
Practice Address - Country:US
Practice Address - Phone:270-443-6490
Practice Address - Fax:270-442-8899
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY53261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice