Provider Demographics
NPI:1851938989
Name:WALLS, KAYLYNN (RDH)
Entity Type:Individual
Prefix:
First Name:KAYLYNN
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MAIN AVE # A
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3543
Mailing Address - Country:US
Mailing Address - Phone:503-964-2732
Mailing Address - Fax:
Practice Address - Street 1:1103 3RD ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3402
Practice Address - Country:US
Practice Address - Phone:503-842-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7953124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist