Provider Demographics
NPI:1427261163
Name:REYNA-WALLING, VIRGINIA (RDH-EA)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:REYNA-WALLING
Suffix:
Gender:F
Credentials:RDH-EA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-3748
Mailing Address - Country:US
Mailing Address - Phone:208-455-5391
Mailing Address - Fax:
Practice Address - Street 1:920 MAIN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3748
Practice Address - Country:US
Practice Address - Phone:208-455-5391
Practice Address - Fax:208-455-7722
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH1337-EA124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist