Provider Demographics
NPI:1720146038
Name:WALTERS, GLENN R SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:R
Last Name:WALTERS
Suffix:SR
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 1:4402 VANCE JACKSON
Mailing Address - Street 2:SUITE 122
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230
Mailing Address - Country:US
Mailing Address - Phone:210-342-2292
Mailing Address - Fax:210-342-2811
Practice Address - Street 1:4402 VANCE JACKSON
Practice Address - Street 2:SUITE 122
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230
Practice Address - Country:US
Practice Address - Phone:210-342-2292
Practice Address - Fax:210-342-2811
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8340122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist