Provider Demographics
NPI:1427378660
Name:WALLING, GORDON LANE (DDS)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:LANE
Last Name:WALLING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301S.CAPITAL OF TEXAS HWY
Mailing Address - Street 2:BLDGA,SUITE132
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-6574
Mailing Address - Country:US
Mailing Address - Phone:512-328-0155
Mailing Address - Fax:
Practice Address - Street 1:1301 S CAPITAL OF TEXAS HWY
Practice Address - Street 2:BLDGA,SUITE132
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-6574
Practice Address - Country:US
Practice Address - Phone:512-328-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice