Provider Demographics
NPI:1114253846
Name:WALL, MATTHEW D (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:WALL
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 CORPORATE CENTER LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5557
Mailing Address - Country:US
Mailing Address - Phone:360-491-7080
Mailing Address - Fax:
Practice Address - Street 1:5320 CORPORATE CENTER LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5557
Practice Address - Country:US
Practice Address - Phone:360-491-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-31
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE600480461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics