Provider Demographics
NPI:1992984173
Name:DR. STEPHEN C. WALLER, DDS, LLC
Entity type:Organization
Organization Name:DR. STEPHEN C. WALLER, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-756-4344
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:110 S. 2ND ST
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2322
Practice Address - Street 1:115 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638
Practice Address - Country:US
Practice Address - Phone:573-756-4344
Practice Address - Fax:573-756-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO19991359821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1578574240OtherTYPE 1 NPI NUMBER