Provider Demographics
NPI:1861528929
Name:WALLER, CHARLES MILTON (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MILTON
Last Name:WALLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 BLUE HAVEN BEACH RD
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2123
Mailing Address - Country:US
Mailing Address - Phone:573-873-5111
Mailing Address - Fax:
Practice Address - Street 1:272 BLUE HAVEN BEACH RD
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-2123
Practice Address - Country:US
Practice Address - Phone:573-873-5111
Practice Address - Fax:573-873-5111
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020299041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice