Provider Demographics
NPI:1881782670
Name:WALTERS, JAY M SR (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:M
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 1:526 N DALEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36322-2000
Mailing Address - Country:US
Mailing Address - Phone:334-598-4994
Mailing Address - Fax:
Practice Address - Street 1:526 N DALEVILLE AVE
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36322-2000
Practice Address - Country:US
Practice Address - Phone:334-598-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL45531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL380241Medicaid
AL820510OtherUCCI
AL515-25448OtherBCBS