Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | DN 21651 | FL |
N | 1223S0112X | Oral and Maxillofacial Surgeon | ME 126426 | FL |
NPI | 1073837746 |
---|---|
Provider Name | Russell Walther |
First Address | Tallahassee, FL 32308-0572 |
Second Address | Tallahassee, FL 32308-0572 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2010 |
Last Update Date | 24/08/2016 |