MEDICARE: DAVID WALD JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1407209257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID WALD JR.

Provider Business Mailing Address
First Line	:	411 E 9TH ST # 7
Second Line	:
City	:	FORT STEWART
State	:	GA
Zip	:	31314-5036
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 VANGUARD RD. BLDG 8335
Second Line	:
City	:	FORT STEWAR
State	:	GA
Zip	:	31314
Country	:	US
Telephone Number	:	912-435-5705
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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