Provider Demographics
NPI:1700016508
Name:CHEN, WALTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:CHEN
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 1:1711 BENSON AVE
Mailing Address - Street 2:2F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3671
Mailing Address - Country:US
Mailing Address - Phone:415-548-0989
Mailing Address - Fax:
Practice Address - Street 1:1711 BENSON AVE
Practice Address - Street 2:2F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-3671
Practice Address - Country:US
Practice Address - Phone:415-548-0989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03362636Medicaid