Provider Demographics
NPI:1659787398
Name:WALTZ, CHAD (DDS)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:WALTZ
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 1:3313 LAS CAMPOS PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-2968
Mailing Address - Country:US
Mailing Address - Phone:319-331-6605
Mailing Address - Fax:
Practice Address - Street 1:625 EICHENFELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5908
Practice Address - Country:US
Practice Address - Phone:813-654-3636
Practice Address - Fax:813-651-4984
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN219831223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics