Healthcare Provider Details

I. General information

NPI: 1427680040
Provider Name (Legal Business Name): LUKE WALN DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25477 MAIN ST
NISSWA MN
56468-5001
US

IV. Provider business mailing address

PO BOX 454
NISSWA MN
56468-0454
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-6330
  • Fax: 218-963-6332
Mailing address:
  • Phone: 218-963-6330
  • Fax: 218-963-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LUKE E WALN
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 218-963-6330