Provider Demographics
NPI:1881787513
Name:WALTER M. MAZZELLA, D.D.S., P.C.
Entity type:Organization
Organization Name:WALTER M. MAZZELLA, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:MAZZELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-203-2552
Mailing Address - Street 1:10775 BIRMINGHAM WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1425
Mailing Address - Country:US
Mailing Address - Phone:410-203-2552
Mailing Address - Fax:410-203-2546
Practice Address - Street 1:10775 BIRMINGHAM WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:WOODSTOCK
Practice Address - State:MD
Practice Address - Zip Code:21163-1425
Practice Address - Country:US
Practice Address - Phone:410-203-2552
Practice Address - Fax:410-203-2546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD121291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty