Provider Demographics
NPI:1275742553
Name:WALTER E GAZDA JR DMD PC
Entity Type:Organization
Organization Name:WALTER E GAZDA JR DMD PC
Other - Org Name:CHURCH STREET DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAZDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-592-2342
Mailing Address - Street 1:109 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020
Mailing Address - Country:US
Mailing Address - Phone:413-592-2342
Mailing Address - Fax:413-592-6608
Practice Address - Street 1:109 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020
Practice Address - Country:US
Practice Address - Phone:413-592-2342
Practice Address - Fax:413-592-6608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA132841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty