Provider Demographics
NPI:1861765943
Name:GEORGE J WALTERS DDS PA
Entity type:Organization
Organization Name:GEORGE J WALTERS DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-763-8585
Mailing Address - Street 1:2202 STATE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7601
Mailing Address - Country:US
Mailing Address - Phone:850-763-8585
Mailing Address - Fax:850-763-3920
Practice Address - Street 1:2202 STATE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7601
Practice Address - Country:US
Practice Address - Phone:850-763-8585
Practice Address - Fax:850-763-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0012432204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL073701101Medicaid
FL073701101Medicaid