Provider Demographics
NPI:1295803245
Name:SNOW, WALTER J (DMD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:J
Last Name:SNOW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:WALTER
Other - Middle Name:J
Other - Last Name:SNOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 7906
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-7906
Mailing Address - Country:US
Mailing Address - Phone:951-371-7200
Mailing Address - Fax:
Practice Address - Street 1:1450 W 6TH ST STE 114
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3066
Practice Address - Country:US
Practice Address - Phone:951-371-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG8925701Medicaid