Provider Demographics
NPI:1013062249
Name:WALLS, RAGONVA SHANTE (DDS)
Entity Type:Individual
Prefix:MS
First Name:RAGONVA
Middle Name:SHANTE
Last Name:WALLS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:RAGONVA
Other - Middle Name:SHANTE
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1273 E RAINES RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-5816
Mailing Address - Country:US
Mailing Address - Phone:901-398-6435
Mailing Address - Fax:901-398-1987
Practice Address - Street 1:1273 E RAINES RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-5816
Practice Address - Country:US
Practice Address - Phone:901-398-6435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice