Provider Demographics
NPI:1285643361
Name:PIEROG, WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:PIEROG
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 1:866 FOSTER STREET EXT
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2116
Mailing Address - Country:US
Mailing Address - Phone:860-644-4209
Mailing Address - Fax:860-644-6646
Practice Address - Street 1:866 FOSTER STREET EXT
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2116
Practice Address - Country:US
Practice Address - Phone:860-644-4209
Practice Address - Fax:860-644-6646
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0063921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice