Provider Demographics
NPI:1811348287
Name:WALLDEN, SAMUEL MOORE (DMD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:MOORE
Last Name:WALLDEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6075 VANTAGE PL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5905
Mailing Address - Country:US
Mailing Address - Phone:815-399-0677
Mailing Address - Fax:
Practice Address - Street 1:6075 VANTAGE PL
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5905
Practice Address - Country:US
Practice Address - Phone:815-399-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0307571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice