Healthcare Provider Details

I. General information

NPI: 1720140817
Provider Name (Legal Business Name): WALTER J. DECK, D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 STATE ROUTE 332 SUITE 1-A
FARMINGTON NY
14425-9601
US

IV. Provider business mailing address

1625 STATE ROUTE 332 SUITE 1-A
FARMINGTON NY
14425-9601
US

V. Phone/Fax

Practice location:
  • Phone: 585-398-3810
  • Fax: 585-398-2413
Mailing address:
  • Phone: 585-398-3810
  • Fax: 585-398-2413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0404321
License Number StateNY

VIII. Authorized Official

Name: DR. WALTER JAMES DECK
Title or Position: OWNER
Credential: D.M.D.
Phone: 585-398-3810