Healthcare Provider Details

I. General information

NPI: 1740263094
Provider Name (Legal Business Name): LUKE E. WALN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25477 MAIN ST NISSWA SMILES
NISSWA MN
56468-5001
US

IV. Provider business mailing address

25477 MAIN ST P.O BOX 454
NISSWA MN
56468-5001
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 NumberD11842
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: