Active NPI
Tonie Waller, DDS
- Dentist
- Ada, OK
National Provider Identifier
1720284458
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 5058
- Practice address
- 1921 Stonecipher Boulevard
Ada, OK 74820-3439 - Phone
- (580) 436-3980
- Fax
- (580) 421-6283
- NPI assigned
- Jun 21, 2007
- Sex
- Male
- Sole proprietor
- No
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 | 5058 | OK | Primary |
Addresses
Primary practice location
1921 Stonecipher Boulevard
Ada, OK 74820-3439
Mailing address
1921 Stonecipher Boulevard
Ada, OK 74820-3439
Phone (580) 436-3980
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150601000407 | TX | Order and Referring Only - Oral Surgery | 3971824111 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5058 | OK | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1182384000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1431907200000",
"number": "1720284458",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1921 STONECIPHER BOULEVARD",
"city": "ADA",
"state": "OK",
"postal_code": "748203439",
"telephone_number": "580-436-3980",
"fax_number": "580-421-6283"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1921 STONECIPHER BOULEVARD",
"city": "ADA",
"state": "OK",
"postal_code": "748203439",
"telephone_number": "580-436-3980",
"fax_number": "580-421-6283"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLER",
"first_name": "TONIE",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-06-21",
"last_updated": "2015-05-18",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "OK",
"license": "5058",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Ada, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 18, 2015; 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.