Provider Demographics
NPI:1104090067
Name:JESSERWALLDDSPA
Entity type:Organization
Organization Name:JESSERWALLDDSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:434-792-1512
Mailing Address - Street 1:1045 MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1800
Mailing Address - Country:US
Mailing Address - Phone:434-792-8622
Mailing Address - Fax:
Practice Address - Street 1:1045 MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1800
Practice Address - Country:US
Practice Address - Phone:434-792-8622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5098OtherVA BOARDOF DENTISTRY