MEDICARE: DR. CHARLES MILTON WALLER 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
1	1223G0001X	General Practice Dentistry	2002029904	MO

General Provider Information

NPI Number	:	1861528929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES MILTON WALLER D.D.S.

Provider Business Mailing Address
First Line	:	272 BLUE HAVEN BEACH RD
Second Line	:
City	:	CAMDENTON
State	:	MO
Zip	:	65020-2123
Country	:	US
Telephone Number	:	573-873-5111
Fax Number	:

Provider Business Practice Location Address
First Line	:	272 BLUE HAVEN BEACH RD
Second Line	:
City	:	CAMDENTON
State	:	MO
Zip	:	65020-2123
Country	:	US
Telephone Number	:	573-873-5111
Fax Number	:	573-873-5111

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

Provider Enumeration Date	:	02/25/2007
Last Update Date	:	12/31/2007

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