Healthcare Provider Details

I. General information

NPI: 1063172468
Provider Name (Legal Business Name): STAPLES SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 6TH ST NE
STAPLES MN
56479-2359
US

IV. Provider business mailing address

515 6TH ST NE
STAPLES MN
56479-2359
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1941
  • Fax: 218-894-5729
Mailing address:
  • Phone: 218-894-1941
  • Fax: 218-894-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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