Provider Demographics
NPI:1679670046
Name:WALLER, MARK O (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:O
Last Name:WALLER
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:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-0229
Mailing Address - Country:US
Mailing Address - Phone:262-246-6806
Mailing Address - Fax:262-246-6892
Practice Address - Street 1:N63 W23401 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-0229
Practice Address - Country:US
Practice Address - Phone:262-246-6806
Practice Address - Fax:262-246-6892
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
799832OtherUNITED CONCORDIA