Provider Demographics
NPI:1720140817
Name:WALTER J. DECK, D.M.D., P.C.
Entity Type:Organization
Organization Name:WALTER J. DECK, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DECK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:585-398-3810
Mailing Address - Street 1:1625 STATE ROUTE 332
Mailing Address - Street 2:SUITE 1-A
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-9601
Mailing Address - Country:US
Mailing Address - Phone:585-398-3810
Mailing Address - Fax:585-398-2413
Practice Address - Street 1:1625 STATE ROUTE 332
Practice Address - Street 2:SUITE 1-A
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-9601
Practice Address - Country:US
Practice Address - Phone:585-398-3810
Practice Address - Fax:585-398-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04043211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1982611661Medicare UPIN