Provider Demographics
NPI:1487752432
Name:DZIALO, WALTER MATTHEW (DDS)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:MATTHEW
Last Name:DZIALO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 TASHMOO WAY
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-3712
Mailing Address - Country:US
Mailing Address - Phone:401-725-4465
Mailing Address - Fax:401-725-0158
Practice Address - Street 1:526 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02861-3612
Practice Address - Country:US
Practice Address - Phone:401-724-2570
Practice Address - Fax:401-724-0199
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN018691223G0001X
MA149661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIWD00135Medicaid