Provider Demographics
NPI:1487990099
Name:MAZZELLA, WALTER MATTHEW (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:MATTHEW
Last Name:MAZZELLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10775 BIRMINGHAM WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1425
Mailing Address - Country:US
Mailing Address - Phone:410-203-2552
Mailing Address - Fax:
Practice Address - Street 1:10775 BIRMINGHAM WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:WOODSTOCK
Practice Address - State:MD
Practice Address - Zip Code:21163-1425
Practice Address - Country:US
Practice Address - Phone:410-203-2552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12129122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist