Provider Demographics
NPI:1255563946
Name:DEREK H. WALL DDS PA
Entity type:Organization
Organization Name:DEREK H. WALL DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:HEATH
Authorized Official - Last Name:WALL DDS PA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-265-3696
Mailing Address - Street 1:801 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2351
Mailing Address - Country:US
Mailing Address - Phone:850-265-3696
Mailing Address - Fax:850-265-2699
Practice Address - Street 1:801 OHIO AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2351
Practice Address - Country:US
Practice Address - Phone:850-265-3696
Practice Address - Fax:850-265-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN140561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty