Provider Demographics
NPI:1902252166
Name:BILTMORE PERIODONTICS, PLLC
Entity Type:Organization
Organization Name:BILTMORE PERIODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-266-5896
Mailing Address - Street 1:1277 E MISSOURI AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2915
Mailing Address - Country:US
Mailing Address - Phone:602-266-5896
Mailing Address - Fax:602-274-6114
Practice Address - Street 1:1277 E MISSOURI AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2915
Practice Address - Country:US
Practice Address - Phone:602-266-5896
Practice Address - Fax:602-274-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0084001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherEIN