Provider Demographics
NPI:1710189261
Name:WALLING, MARK WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
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 1:1008 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-3602
Mailing Address - Country:US
Mailing Address - Phone:516-582-5779
Mailing Address - Fax:718-919-7906
Practice Address - Street 1:1008 GATES AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-3602
Practice Address - Country:US
Practice Address - Phone:516-582-5779
Practice Address - Fax:718-919-7906
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010049471223G0001X
NY0316241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0300XDental ProvidersDentistPeriodontics