Organization
DR. STEPHEN C. WALLER, DDS, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. STEPHEN C. WALLER D.D.S. (DENTIST)
(573) 756-4344
Entity
Organization
Contact information
Practice address
115 WALNUT ST, ELLINGTON, MO 63638
(573) 756-4344
(573) 756-4699
Mailing address
PO BOX 157, 110 S. 2ND ST, ELLINGTON, MO 63638-0157
(573) 663-2313
(573) 663-2322
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
1999135982
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1578574240
TYPE 1 NPI NUMBER
MO
Enumeration date
10/24/2007
Last updated
01/22/2009
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