Samuel Moore Wallden, D.M.D.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

019.030757 Issued in IL

Practice address

6075 Vantage PL
Rockford, IL 61107-5905

Phone

(815) 399-0677

NPI assigned

Jun 28, 2016

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

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

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

{
    "created_epoch": "1467072000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1467072000000",
    "number": "1811348287",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6075 VANTAGE PL",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611075905",
            "telephone_number": "815-399-0677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6075 VANTAGE PL",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611075905",
            "telephone_number": "815-399-0677"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLDEN",
        "first_name": "SAMUEL",
        "middle_name": "MOORE",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2016-06-28",
        "last_updated": "2016-06-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019.030757",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jimmy L Walker Jr., PA-C
• Lashonda Walker
• John Wall, MD
• Adam N Wallace, MD
• Kiley Wallden, OTR/L
• Shawn Steven Wallery, D.C., M.D.
• Walmart Inc.
• Walmart Inc.
• Walmart Inc.
• Caitlin Ray Walsh, LPC

• General Practice Dentistry in Rockford, IL
• Providers in Rockford, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2016; 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.