Provider Demographics
NPI:1215164512
Name:WALLNER, KAMI K (DDS)
Entity type:Individual
Prefix:DR
First Name:KAMI
Middle Name:K
Last Name:WALLNER
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 1:6453 SCENIC HWY NE
Mailing Address - Street 2:
Mailing Address - City:BLACKDUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56630-4340
Mailing Address - Country:US
Mailing Address - Phone:612-210-9267
Mailing Address - Fax:
Practice Address - Street 1:101 EAST MAIN STREET
Practice Address - Street 2:SUITE 108
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016000084122300000X
CO9963122300000X, 122300000X
MND12690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist