Provider Demographics
NPI:1821593807
Name:WALLER, DANIEL JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
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 1:435 WELLS ST APT 207
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1465
Mailing Address - Country:US
Mailing Address - Phone:414-460-7456
Mailing Address - Fax:
Practice Address - Street 1:N63W23401 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089
Practice Address - Country:US
Practice Address - Phone:262-246-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001877-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist