Provider Demographics
NPI:1629067384
Name:VALLA, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VALLA
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:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-926-6992
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-5908
Practice Address - Fax:518-926-5909
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000491895001OtherBLUE SHIELD NENY