Provider Demographics
NPI:1952839854
Name:VANDE WALLE, TOREY J (DDS)
Entity Type:Individual
Prefix:
First Name:TOREY
Middle Name:J
Last Name:VANDE WALLE
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 1:1800 STATE ROAD 16
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3011
Mailing Address - Country:US
Mailing Address - Phone:920-737-6701
Mailing Address - Fax:
Practice Address - Street 1:1800 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3011
Practice Address - Country:US
Practice Address - Phone:608-782-9667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001518151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice