Provider Demographics
NPI:1497733463
Name:MAZZELLA, WALTER JOHN (DDS, MS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JOHN
Last Name:MAZZELLA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 JENIFER ST NW
Mailing Address - Street 2:#335
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015
Mailing Address - Country:US
Mailing Address - Phone:202-966-3132
Mailing Address - Fax:202-966-0470
Practice Address - Street 1:4400 JENIFER ST NW
Practice Address - Street 2:#335
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015
Practice Address - Country:US
Practice Address - Phone:202-966-3132
Practice Address - Fax:202-966-0470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN2174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist