Provider Demographics
NPI:1275194771
Name:WALPOLE, CHANDLER L (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHANDLER
Middle Name:L
Last Name:WALPOLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3327 W CAPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-1334
Mailing Address - Country:US
Mailing Address - Phone:308-382-4297
Mailing Address - Fax:
Practice Address - Street 1:3327 W CAPITAL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-1334
Practice Address - Country:US
Practice Address - Phone:308-382-4297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE75761223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health