Provider Demographics
NPI:1770633075
Name:WALTERS FAMILY DENISTRY
Entity type:Organization
Organization Name:WALTERS FAMILY DENISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-353-6425
Mailing Address - Street 1:3461 WARRENSVILLE CENTER RD STE 301
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5227
Mailing Address - Country:US
Mailing Address - Phone:216-382-1102
Mailing Address - Fax:
Practice Address - Street 1:3461 WARRENSVILLE CENTER RD STE 301
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5227
Practice Address - Country:US
Practice Address - Phone:216-382-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
124Q00000X, 126800000X
OH0202381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty