Provider Demographics
NPI:1760515035
Name:WALL, KEVIN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:WALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:KY
Mailing Address - Zip Code:41073-1175
Mailing Address - Country:US
Mailing Address - Phone:859-291-7621
Mailing Address - Fax:859-291-0048
Practice Address - Street 1:340 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073-1175
Practice Address - Country:US
Practice Address - Phone:859-291-7621
Practice Address - Fax:859-291-0048
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice