Provider Demographics
NPI:1649458910
Name:KOSTRZEWSKI, WALTER (DMD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:KOSTRZEWSKI
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 1:203 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3501
Mailing Address - Country:US
Mailing Address - Phone:203-876-9887
Mailing Address - Fax:203-876-7513
Practice Address - Street 1:203 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3501
Practice Address - Country:US
Practice Address - Phone:203-876-9887
Practice Address - Fax:203-876-7513
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist