Provider Demographics
NPI:1063816163
Name:VALDIVIA, WALDO OLIVER (DDS)
Entity Type:Individual
Prefix:
First Name:WALDO
Middle Name:OLIVER
Last Name:VALDIVIA
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 1:9554 OLD KEENE MILL RD STE C
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4287
Mailing Address - Country:US
Mailing Address - Phone:703-952-4003
Mailing Address - Fax:571-281-0001
Practice Address - Street 1:9554 OLD KEENE MILL RD STE C
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-4287
Practice Address - Country:US
Practice Address - Phone:703-952-4003
Practice Address - Fax:571-281-0001
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014163531223G0001X
MADL12425122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist