Provider Demographics
NPI:1629214820
Name:WALL, MATTHEW RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
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 1:625 W SOUTHERN AVE STE E-145
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-5030
Mailing Address - Country:US
Mailing Address - Phone:602-759-2131
Mailing Address - Fax:
Practice Address - Street 1:625 W SOUTHERN AVE STE E-145
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-5030
Practice Address - Country:US
Practice Address - Phone:602-759-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57242122300000X
AZD79901223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ535955Medicaid