Provider Demographics
NPI:1801458633
Name:WALAG, KIMBERLY MICHELLE (DDS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MICHELLE
Last Name:WALAG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 MARK CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9294
Mailing Address - Country:US
Mailing Address - Phone:574-329-2955
Mailing Address - Fax:
Practice Address - Street 1:117 E HOUSTON ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4509
Practice Address - Country:US
Practice Address - Phone:281-592-0597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist