Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 007677 | CT |
NPI | 1033128954 |
---|---|
Provider Name | Walter John Leckowiczjr |
First Address | Newington, CT 06111 |
Second Address | Newington, CT 06111-2914 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2006 |
Last Update Date | 08/07/2007 |