Provider Demographics
NPI:1932341542
Name:WALTERS, TODD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:W
Last Name:WALTERS
Suffix:
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 1:800 FULTON ST STE 4A
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1579
Mailing Address - Country:US
Mailing Address - Phone:574-722-5313
Mailing Address - Fax:574-753-3025
Practice Address - Street 1:800 FULTON ST STE 4A
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1579
Practice Address - Country:US
Practice Address - Phone:574-722-5313
Practice Address - Fax:574-753-3025
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008831A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100070910Medicaid