MEDICARE: DR. RENEE A WALL DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6732	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9008P	OTHER	NC	BCBS
2	811370	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1114007721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENEE A WALL DDS

Provider Business Mailing Address
First Line	:	100 HYANNIS DR
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-8327
Country	:	US
Telephone Number	:	919-362-1394
Fax Number	:	919-362-1638

Provider Business Practice Location Address
First Line	:	100 HYANNIS DR
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-8327
Country	:	US
Telephone Number	:	919-362-1394
Fax Number	:	919-362-1638

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	07/06/2011

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Directions to “ DR. RENEE A WALL DDS” Practice Location

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