Provider Demographics
NPI:1164476172
Name:WALO, ROSALIE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSALIE
Middle Name:A
Last Name:WALO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 UNIVERSITY BLVD N
Mailing Address - Street 2:MC - 75
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-9230
Mailing Address - Country:US
Mailing Address - Phone:904-253-2062
Mailing Address - Fax:904-253-1942
Practice Address - Street 1:5150 TIMUQUANA RD.
Practice Address - Street 2:SUITE 9
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-8925
Practice Address - Country:US
Practice Address - Phone:904-253-1680
Practice Address - Fax:904-253-2509
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN129811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075227400Medicaid
FL0752274-00Medicaid