Provider Demographics
NPI:1508611146
Name:WALLER, CHASE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHASE
Middle Name:
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 1:2640 S UNIVERSITY DR APT 217
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1477
Mailing Address - Country:US
Mailing Address - Phone:727-678-9836
Mailing Address - Fax:
Practice Address - Street 1:2643 RANDLEMAN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-5153
Practice Address - Country:US
Practice Address - Phone:336-544-2758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program