Healthcare Provider Details

I. General information

NPI: 1629214820
Provider Name (Legal Business Name): MATTHEW RYAN WALL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W SOUTHERN AVE STE E-145
MESA AZ
85210-5030
US

IV. Provider business mailing address

625 W SOUTHERN AVE STE E-145
MESA AZ
85210-5030
US

V. Phone/Fax

Practice location:
  • Phone: 602-759-2131
  • Fax:
Mailing address:
  • Phone: 602-759-2131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number57242
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberD7990
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: