Provider Demographics
NPI:1073588562
Name:WALLE, NEIL MARION (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:MARION
Last Name:WALLE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6012
Mailing Address - Country:US
Mailing Address - Phone:541-884-8668
Mailing Address - Fax:541-885-4854
Practice Address - Street 1:808 MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6012
Practice Address - Country:US
Practice Address - Phone:541-884-8668
Practice Address - Fax:541-885-4854
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD67511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics