Provider Demographics
NPI:1164716783
Name:WALLIN, KURT DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:DAVID
Last Name:WALLIN
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 1:3648 E JANELLE WAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-4836
Mailing Address - Country:US
Mailing Address - Phone:480-432-2000
Mailing Address - Fax:
Practice Address - Street 1:2934 W INA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2110
Practice Address - Country:US
Practice Address - Phone:480-432-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038653122300000X
AZD0084001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist