Provider Demographics
NPI:1548483845
Name:MARTIN, WALTER D (DMD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-5346
Mailing Address - Country:US
Mailing Address - Phone:308-237-5853
Mailing Address - Fax:308-237-5089
Practice Address - Street 1:2205 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5346
Practice Address - Country:US
Practice Address - Phone:308-237-5853
Practice Address - Fax:308-237-5089
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE51041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100252765-00Medicaid