Individual
MARK O WALLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
N63 W23401 MAIN ST, SUSSEX, WI 53089-0229
(262) 246-6806
(262) 246-6892
Mailing address
PO BOX 229, SUSSEX, WI 53089-0229
(262) 246-6806
(262) 246-6892
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
3012
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
799832
UNITED CONCORDIA
—
Enumeration date
09/20/2006
Last updated
07/08/2007
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