Provider Demographics
NPI:1083509202
Name:WALTERS, LEVI (DDS)
Entity type:Individual
Prefix:
First Name:LEVI
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1797 E FIRESIDE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1116
Mailing Address - Country:US
Mailing Address - Phone:864-553-4425
Mailing Address - Fax:
Practice Address - Street 1:1311 E CENTRAL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7991
Practice Address - Country:US
Practice Address - Phone:208-373-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8171062122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist