Provider Demographics
NPI:1972987550
Name:WALTZ CENTER FOR ORAL SURGERY & IMPLANTOLOGY, PC
Entity type:Organization
Organization Name:WALTZ CENTER FOR ORAL SURGERY & IMPLANTOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RIBERT
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:WALTZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-227-9959
Mailing Address - Street 1:16327 MOUNT AIRY RD
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17361-1624
Mailing Address - Country:US
Mailing Address - Phone:717-227-9959
Mailing Address - Fax:717-227-1262
Practice Address - Street 1:16327 MOUNT AIRY RD
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:PA
Practice Address - Zip Code:17361-1624
Practice Address - Country:US
Practice Address - Phone:717-227-9959
Practice Address - Fax:717-227-1262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023711L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA509949ZAVDMedicare UPIN