Active NPI
Kory Wallin, DMD
- Dentist
- Longmont, CO
National Provider Identifier
1477818052
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 10742
- Practice address
- 1100 Ken Pratt Blvd Ste E
Longmont, CO 80501-6380 - Phone
- (720) 458-6684
- NPI assigned
- Jul 10, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 10742 | CO | Primary |
Addresses
Primary practice location
1100 Ken Pratt Blvd Ste E
Longmont, CO 80501-6380
Mailing address
1100 Ken Pratt Blvd Unit E
Longmont, CO 80501
Phone (720) 505-9422
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10742 | CO | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1341878400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1676592000000",
"number": "1477818052",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1100 KEN PRATT BLVD UNIT E",
"city": "LONGMONT",
"state": "CO",
"postal_code": "80501",
"telephone_number": "720-505-9422"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1100 KEN PRATT BLVD STE E",
"city": "LONGMONT",
"state": "CO",
"postal_code": "805016380",
"telephone_number": "720-458-6684"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLIN",
"first_name": "KORY",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-07-10",
"last_updated": "2023-02-17",
"certification_date": "2023-02-17",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CO",
"license": "10742",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Longmont, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.