Provider Demographics
NPI:1376985655
Name:WALL, CHARLES COLEMAN (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:COLEMAN
Last Name:WALL
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 1:2200 E 4500 S
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4437
Mailing Address - Country:US
Mailing Address - Phone:801-278-3864
Mailing Address - Fax:801-278-3868
Practice Address - Street 1:2200 E 4500 S
Practice Address - Street 2:SUITE 240
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4437
Practice Address - Country:US
Practice Address - Phone:801-278-3864
Practice Address - Fax:801-278-3868
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5134366-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist