Provider Demographics
NPI:1457633851
Name:WALDMAN, BRIAN ERNEST (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ERNEST
Last Name:WALDMAN
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 1:1410 SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4040
Mailing Address - Country:US
Mailing Address - Phone:217-502-9780
Mailing Address - Fax:
Practice Address - Street 1:1410 SEMINARY ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4040
Practice Address - Country:US
Practice Address - Phone:217-502-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110306641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice