Provider Demographics
NPI:1497968572
Name:WALLS, KEVIN W (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:WALLS
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 1:1160 OLD PEACHTREE RD
Mailing Address - Street 2:STE B
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:678-473-7770
Mailing Address - Fax:678-473-1066
Practice Address - Street 1:1160 OLD PEACHTREE RD
Practice Address - Street 2:STE B
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:678-473-7770
Practice Address - Fax:678-473-1066
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0097871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice