Provider Demographics
NPI:1649269283
Name:WALLEY, AMA D (DMD)
Entity type:Individual
Prefix:
First Name:AMA
Middle Name:D
Last Name:WALLEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3339
Mailing Address - Country:US
Mailing Address - Phone:484-454-3230
Mailing Address - Fax:
Practice Address - Street 1:1220 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-3339
Practice Address - Country:US
Practice Address - Phone:484-454-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN031436A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0182803704Medicaid