Provider Demographics
NPI:1407098197
Name:WALLER, CARTER MILAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARTER
Middle Name:MILAN
Last Name:WALLER
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 1:1417 PARCELL ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4616
Mailing Address - Country:US
Mailing Address - Phone:540-899-1777
Mailing Address - Fax:540-899-2266
Practice Address - Street 1:1417 PARCELL ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4616
Practice Address - Country:US
Practice Address - Phone:540-899-1777
Practice Address - Fax:540-899-2266
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL152511223G0001X
VA04014109471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice