Provider Demographics
NPI:1467462002
Name:WALL, DOUGLAS R (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
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 1:5479 E ABBEYFIELD ST
Mailing Address - Street 2:# 4
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3050
Mailing Address - Country:US
Mailing Address - Phone:562-597-1414
Mailing Address - Fax:562-498-6174
Practice Address - Street 1:5479 E ABBEYFIELD ST
Practice Address - Street 2:#4
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-3050
Practice Address - Country:US
Practice Address - Phone:562-597-1414
Practice Address - Fax:562-498-6174
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31417122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT82741Medicare UPIN