Provider Demographics
NPI:1316227606
Name:WALLA, MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WALLA
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 1:3985 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3404
Mailing Address - Country:US
Mailing Address - Phone:716-832-1550
Mailing Address - Fax:
Practice Address - Street 1:3985 MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3404
Practice Address - Country:US
Practice Address - Phone:716-832-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0551701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics