Provider Demographics
NPI:1710032446
Name:MCGINN, WALTER PHILLIP (DMD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:PHILLIP
Last Name:MCGINN
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 1:153 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2115
Mailing Address - Country:US
Mailing Address - Phone:860-928-3723
Mailing Address - Fax:
Practice Address - Street 1:153 GROVE ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2115
Practice Address - Country:US
Practice Address - Phone:860-928-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8004122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004397750Medicaid