Jordan Myungdo Walle

Primary specialty

Public Health DentistryTaxonomy code 1223D0001X

License

D11718 Issued in OR

Practice address

2074 S 6TH St
Klamath Falls, OR 97601-3372

Phone

(541) 851-8110

NPI assigned

Feb 23, 2022

Last updated

Jul 30, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OR

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

Practice roles

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

• Waimanalo Health Center

  • Federally Qualified Health Center (FQHC)
  • Waimanalo, HI
  • NPI 1952073397
  NPD (past)

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

{
    "created_epoch": "1645574400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1722297600000",
    "number": "1780330282",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2074 S 6TH ST",
            "city": "KLAMATH FALLS",
            "state": "OR",
            "postal_code": "976013372",
            "telephone_number": "541-851-8110"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2074 S 6TH ST",
            "city": "KLAMATH FALLS",
            "state": "OR",
            "postal_code": "976013372",
            "telephone_number": "541-851-8110"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLE",
        "first_name": "JORDAN",
        "middle_name": "MYUNGDO",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2022-02-23",
        "last_updated": "2024-07-30",
        "certification_date": "2024-07-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223D0001X",
            "taxonomy_group": "",
            "desc": "Dentist, Dental Public Health",
            "state": "OR",
            "license": "D11718",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500822026",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sarah Anne Walker, QMHP-R
• Susan Marie Walker, QMHA
• Dawn Wallace, CHW
• Garrett Gene Wallace, DC
• Scott G Wallace, D.C.
• Neil Marion Walle, D.D.S., M.S.
• Ronnie Lee Walles
• Chelcee Walls, CARE MANAGER
• Walmart Inc. (Wal-Mart Pharmacy 10-1772)
• Elaine T. Walters

• Public Health Dentistry in Klamath Falls, OR
• Providers in Klamath Falls, OR by specialty
• Public Health Dentistry in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 30, 2024; 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.