Provider Demographics
NPI:1932255627
Name:WALL, TIMOTHY RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RAYMOND
Last Name:WALL
Suffix:
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 1:250 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3529
Mailing Address - Country:US
Mailing Address - Phone:262-695-9392
Mailing Address - Fax:
Practice Address - Street 1:250 CLARK ST
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3529
Practice Address - Country:US
Practice Address - Phone:262-695-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3951-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice