Healthcare Provider Details

I. General information

NPI: 1528286366
Provider Name (Legal Business Name): GREGORY DEAN WALES HID
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 BROADWAY ST SUITE#1
ALEXANDRIA MN
56308-2537
US

IV. Provider business mailing address

1501 BROADWAY SUITE#1
ALEXANDRIA MN
56308
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-2505
  • Fax: 320-763-9010
Mailing address:
  • Phone: 320-762-2505
  • Fax: 320-763-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2034
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: