Provider Demographics
NPI:1104041763
Name:WALLEY, DONALD GAVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:GAVIN
Last Name:WALLEY
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 1:7730 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1708
Mailing Address - Country:US
Mailing Address - Phone:901-755-6440
Mailing Address - Fax:901-755-6436
Practice Address - Street 1:7730 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1708
Practice Address - Country:US
Practice Address - Phone:901-755-6440
Practice Address - Fax:901-755-6436
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS46751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621683022OtherTAX ID #