Basic Information
| Provider Information | |||||||||
| NPI: | 1285214221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE S STE 901 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483114 | ||||||||
| FaxNumber: | 2062620859 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 12TH AVE S STE 401 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065485850 | ||||||||
| FaxNumber: | 2063284034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 122300000X | DE61275113 | WA | Y | Dental Providers | Dentist |
No ID Information.