Provider Demographics
NPI:1245801174
Name:WALCZAK, PHILIP A (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:WALCZAK
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 1:9730 3RD AVE NE STE 105
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2023
Mailing Address - Country:US
Mailing Address - Phone:425-350-8479
Mailing Address - Fax:
Practice Address - Street 1:9730 3RD AVE NE STE 105
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2023
Practice Address - Country:US
Practice Address - Phone:206-526-1985
Practice Address - Fax:206-526-0466
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611575501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice