Provider Demographics
NPI:1497786248
Name:WALL, AUSTIN A (DDS)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:A
Last Name:WALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:AUSTIN
Other - Middle Name:A
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2233 MARTIN
Mailing Address - Street 2:218
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1455
Mailing Address - Country:US
Mailing Address - Phone:949-502-7850
Mailing Address - Fax:949-387-6095
Practice Address - Street 1:2233 MARTIN
Practice Address - Street 2:218
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1455
Practice Address - Country:US
Practice Address - Phone:949-502-7850
Practice Address - Fax:949-387-6095
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26795122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist