Provider Demographics
NPI:1639482474
Name:WALLER, JAIME BETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:BETH
Last Name:WALLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:BETH
Other - Last Name:WIEBUSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:DEERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56444
Mailing Address - Country:US
Mailing Address - Phone:218-534-3141
Mailing Address - Fax:218-534-3949
Practice Address - Street 1:21343 ARCHIBALD ROAD
Practice Address - Street 2:
Practice Address - City:DEERWOOD
Practice Address - State:MN
Practice Address - Zip Code:56444
Practice Address - Country:US
Practice Address - Phone:218-534-3141
Practice Address - Fax:218-534-3949
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND128401223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice