MEDICARE: KIMBERLY MICHELLE WALAG DDS

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
1	122300000X	Dentist	35341	TX

General Provider Information

NPI Number	:	1801458633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MICHELLE WALAG DDS

Provider Business Mailing Address
First Line	:	12720 MARK CT
Second Line	:
City	:	GRANGER
State	:	IN
Zip	:	46530-9294
Country	:	US
Telephone Number	:	574-329-2955
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 E HOUSTON ST
Second Line	:
City	:	CLEVELAND
State	:	TX
Zip	:	77327-4509
Country	:	US
Telephone Number	:	281-592-0597
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2019
Last Update Date	:	07/16/2019

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