Healthcare Provider Details

I. General information

NPI: 1457029167
Provider Name (Legal Business Name): PABLO MADRIGAL WALLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E SERVICE RD
CERES CA
95307-6422
US

IV. Provider business mailing address

1547 CONCERTO LN # LM
HUGHSON CA
95326-9136
US

V. Phone/Fax

Practice location:
  • Phone: 209-542-9921
  • Fax:
Mailing address:
  • Phone: 209-484-3078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: