Provider Demographics
NPI:1740519313
Name:WALL STREET DENTISTRY LLC
Entity type:Organization
Organization Name:WALL STREET DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:LAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAPLES
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:256-878-0525
Mailing Address - Street 1:65 WALL ST
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35951-7392
Mailing Address - Country:US
Mailing Address - Phone:256-878-0525
Mailing Address - Fax:256-878-0521
Practice Address - Street 1:65 WALL ST
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35951-7392
Practice Address - Country:US
Practice Address - Phone:256-878-0525
Practice Address - Fax:256-878-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6626390001Medicare NSC