Healthcare Provider Details

I. General information

NPI: 1891880720
Provider Name (Legal Business Name): WILLIAM H. WALL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5139 JIMMY CARTER BLVD STE 201
NORCROSS GA
30093-1638
US

IV. Provider business mailing address

5139 JIMMY CARTER BLVD STE 201
NORCROSS GA
30093-1638
US

V. Phone/Fax

Practice location:
  • Phone: 770-448-0966
  • Fax: 770-448-8549
Mailing address:
  • Phone: 770-448-0966
  • Fax: 770-448-8549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number6817
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: