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NPI Code Detail

MEDICARE: DR. DOUGLAS GLEN WALESHECK D.D.S.

MEDICARE: DR. DOUGLAS GLEN WALESHECK D.D.S.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice DentistryD7367MN

General Provider Information

NPI Number : 1043295132
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DOUGLAS GLEN WALESHECK D.D.S.
Provider Business Mailing Address
First Line : 1346 PAYNE AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55101-3434
Country : US
Telephone Number : 651-774-6085
Fax Number : 651-774-2660
Provider Business Practice Location Address
First Line : 1346 PAYNE AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55101-3434
Country : US
Telephone Number : 651-774-6085
Fax Number : 651-774-2660
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/12/2005
Last Update Date : 07/08/2007

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