Provider Demographics
NPI:1396898847
Name:PEDIATRIC DENTISTRY, P.C.
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:FRED
Authorized Official - Last Name:THAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-224-2419
Mailing Address - Street 1:1 LAKE ST
Mailing Address - Street 2:BUILDING B
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1396
Mailing Address - Country:US
Mailing Address - Phone:860-224-2419
Mailing Address - Fax:860-224-3095
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:BUILDING B
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:860-224-2419
Practice Address - Fax:860-224-3095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty