Healthcare Provider Details

I. General information

NPI: 1881787513
Provider Name (Legal Business Name): WALTER M. MAZZELLA, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10775 BIRMINGHAM WAY SUITE 1
WOODSTOCK MD
21163-1425
US

IV. Provider business mailing address

10775 BIRMINGHAM WAY SUITE 1
WOODSTOCK MD
21163-1425
US

V. Phone/Fax

Practice location:
  • Phone: 410-203-2552
  • Fax: 410-203-2546
Mailing address:
  • Phone: 410-203-2552
  • Fax: 410-203-2546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12129
License Number StateMD

VIII. Authorized Official

Name: WALTER MATTHEW MAZZELLA
Title or Position: PRESIDENT CEO
Credential: D.D.S.
Phone: 410-203-2552