Provider Demographics
NPI:1245359413
Name:WALLSTROM, JOHN B (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:WALLSTROM
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 1:1340 8TH ST NE
Mailing Address - Street 2:#102
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4700
Mailing Address - Country:US
Mailing Address - Phone:253-939-0055
Mailing Address - Fax:
Practice Address - Street 1:1340 8TH ST NE
Practice Address - Street 2:#102
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4700
Practice Address - Country:US
Practice Address - Phone:253-939-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE65581223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics