Provider Demographics
NPI:1982726618
Name:FOSBURY, WALTER JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:JAY
Last Name:FOSBURY
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 1:1800 MCRAE BLVD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-6706
Mailing Address - Country:US
Mailing Address - Phone:915-592-4168
Mailing Address - Fax:915-591-5014
Practice Address - Street 1:1800 MCRAE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-6706
Practice Address - Country:US
Practice Address - Phone:915-592-4168
Practice Address - Fax:915-591-5014
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics