Healthcare Provider Details

I. General information

NPI: 1275194771
Provider Name (Legal Business Name): CHANDLER L. WALPOLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3327 W CAPITAL AVE
GRAND ISLAND NE
68803-1334
US

IV. Provider business mailing address

3327 W CAPITAL AVE
GRAND ISLAND NE
68803-1334
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-4297
  • Fax:
Mailing address:
  • Phone: 308-382-4297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number7576
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: