Provider Demographics
NPI:1629117874
Name:FELDMAN, WALTER B (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:B
Last Name:FELDMAN
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 1:150 ISLIP AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-3222
Mailing Address - Country:US
Mailing Address - Phone:631-581-6565
Mailing Address - Fax:631-581-6574
Practice Address - Street 1:150 ISLIP AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3222
Practice Address - Country:US
Practice Address - Phone:631-581-6565
Practice Address - Fax:631-581-6574
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0306601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00431012Medicaid