Provider Demographics
NPI:1215996087
Name:WALLIN, CARL STEPHEN (DDS)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:STEPHEN
Last Name:WALLIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 1ST AVE SW, PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1503
Mailing Address - Country:US
Mailing Address - Phone:320-634-4543
Mailing Address - Fax:320-634-4544
Practice Address - Street 1:101 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1503
Practice Address - Country:US
Practice Address - Phone:320-634-4543
Practice Address - Fax:320-634-4544
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12086122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist