Provider Demographics
NPI:1306041140
Name:BLUMENFELD, WALTER LAWRENCE (DDS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:LAWRENCE
Last Name:BLUMENFELD
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 1:1804 BROOK AVENUE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301
Mailing Address - Country:US
Mailing Address - Phone:940-322-2252
Mailing Address - Fax:940-322-7090
Practice Address - Street 1:1804 BROOK AVENUE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301
Practice Address - Country:US
Practice Address - Phone:940-322-2252
Practice Address - Fax:940-322-7090
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP107981223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP10798OtherLICENSE NUMBER