Provider Demographics
NPI:1871702407
Name:WALDBART, RICHARD HAMILTON (DMD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:HAMILTON
Last Name:WALDBART
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4627 W LEONA ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-7645
Mailing Address - Country:US
Mailing Address - Phone:813-839-1347
Mailing Address - Fax:
Practice Address - Street 1:4208 W BAY TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6608
Practice Address - Country:US
Practice Address - Phone:813-837-3476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL47751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice