Healthcare Provider Details

I. General information

NPI: 1114031473
Provider Name (Legal Business Name): WILLIAM WALSTAD D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 WORTH ST
DALLAS TX
75246-1608
US

IV. Provider business mailing address

4015 WORTH ST
DALLAS TX
75246-1608
US

V. Phone/Fax

Practice location:
  • Phone: 214-823-5444
  • Fax: 214-823-1581
Mailing address:
  • Phone: 214-823-5444
  • Fax: 214-823-1581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number17914
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: