Provider Demographics
NPI:1821074527
Name:WALL, GARY A JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:WALL
Suffix:JR
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 1:10627 19TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5147
Mailing Address - Country:US
Mailing Address - Phone:425-337-6553
Mailing Address - Fax:425-385-8943
Practice Address - Street 1:10627 19TH AVE SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5147
Practice Address - Country:US
Practice Address - Phone:425-337-6553
Practice Address - Fax:425-385-8943
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA08241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist