Provider Demographics
NPI:1780722959
Name:SANDUSKY, WALTER COOPER III (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:COOPER
Last Name:SANDUSKY
Suffix:III
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 1:6262 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4728
Mailing Address - Country:US
Mailing Address - Phone:901-761-3700
Mailing Address - Fax:901-680-0403
Practice Address - Street 1:6262 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4728
Practice Address - Country:US
Practice Address - Phone:901-761-3700
Practice Address - Fax:901-680-0403
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0037820OtherBCBS OF TENNSSEE
TN832857OtherUNITED CONCORDIA