Mark O Waller, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

3012 Issued in WI

Practice address

N63 W23401 Main St
Sussex, WI 53089-0229

Phone

(262) 246-6806

Fax

(262) 246-6892

NPI assigned

Sep 20, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Deborah a Archilletti DDS SC

  • Dentist
  • Sussex, WI
  • NPI 1578625372
  NPD (past)
• Karen M. Boettcher, D.D.S.,S.C.

  • General Practice Dentistry
  • Sussex, WI
  • NPI 1023197910
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1679670046",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 229",
            "city": "SUSSEX",
            "state": "WI",
            "postal_code": "530890229",
            "telephone_number": "262-246-6806",
            "fax_number": "262-246-6892"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "N63 W23401 MAIN ST",
            "city": "SUSSEX",
            "state": "WI",
            "postal_code": "530890229",
            "telephone_number": "262-246-6806",
            "fax_number": "262-246-6892"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "MARK",
        "middle_name": "O",
        "credential": "D.D.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-09-20",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WI",
            "license": "3012",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "799832",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Linda S Vogel, P.A
• Randal Leonard Vosters, MD
• Alice Waech
• Walgreen Co
• Daniel James Waller, DMD
• Wendy Wallis, RPH
• Ellen M Wanta, LAT
• Buffi R Wargolet
• Kelly M Webster, RDN
• Ashley R Werner, RD

• General Practice Dentistry in Sussex, WI
• Providers in Sussex, WI by specialty
• General Practice Dentistry in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.