Provider Demographics
NPI:1245241512
Name:WALLING, GREG T (DDS)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:T
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 1:5001 AMERICAN BLVD W
Mailing Address - Street 2:SUITE 905
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1108
Mailing Address - Country:US
Mailing Address - Phone:952-835-2888
Mailing Address - Fax:952-835-0777
Practice Address - Street 1:5001 AMERICAN BLVD W
Practice Address - Street 2:SUITE 905
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1108
Practice Address - Country:US
Practice Address - Phone:952-835-2888
Practice Address - Fax:952-835-0777
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice