Provider Demographics
NPI:1861592081
Name:WALTERS, RANDY P (DMD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:P
Last Name:WALTERS
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 1:632 W FRONT ST N
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-5316
Mailing Address - Country:US
Mailing Address - Phone:334-636-2713
Mailing Address - Fax:334-636-2711
Practice Address - Street 1:632 W FRONT ST N
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-5316
Practice Address - Country:US
Practice Address - Phone:334-636-2713
Practice Address - Fax:334-636-2711
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL149122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009943710Medicaid
AL009943710Medicaid