Healthcare Provider Details

I. General information

NPI: 1184648610
Provider Name (Legal Business Name): JAMES ALFRED WALZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 W BROADWAY
PLAINVIEW MN
55964-1256
US

IV. Provider business mailing address

338 W BROADWAY
PLAINVIEW MN
55964-1256
US

V. Phone/Fax

Practice location:
  • Phone: 507-534-2675
  • Fax:
Mailing address:
  • Phone: 507-534-2675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7943
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier36315WA
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier5030361
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMN TAX ID NUMBER
# 3
Identifier1243500
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMN REVENUE TAXPAYER ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: