Healthcare Provider Details

I. General information

NPI: 1114844750
Provider Name (Legal Business Name): LYNDAN NAM WALLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N 1ST AVE
STAYTON OR
97383-1703
US

IV. Provider business mailing address

521 N 1ST AVE
STAYTON OR
97383-1703
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-9699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD12378
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: