=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215164512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAMI K WALLNER DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2009
-----------------------------------------------------
Last Update Date | 07/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 EAST MAIN STREET SUITE 108
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-668-1029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6453 SCENIC HWY NE
-----------------------------------------------------
City | BLACKDUCK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56630-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-210-9267
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2016000084
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9963
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------