Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 3332 | ME |
NPI | 1134215734 |
---|---|
Provider Name | Dr. Walter J Serwatka |
First Address | Hampton, VA 23664-1751 |
Second Address | Hampton, VA 23664-1751 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 08/07/2007 |