Basic Information
| Provider Information | |||||||||
| NPI: | 1144409509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORHEAD | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1140 | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999291140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078743731 | ||||||||
| FaxNumber: | 9078743531 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | WRANGELL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999291140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078743731 | ||||||||
| FaxNumber: | 9078743531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 550 | AK | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | DD0550 | 05 | AK | MEDICAID |