Healthcare Provider Details

I. General information

NPI: 1922588250
Provider Name (Legal Business Name): WALLS FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 E ERIE ST
MISSOURI VALLEY IA
51555-1644
US

IV. Provider business mailing address

413 E ERIE ST
MISSOURI VALLEY IA
51555-1644
US

V. Phone/Fax

Practice location:
  • Phone: 712-642-3671
  • Fax: 712-642-4155
Mailing address:
  • Phone: 712-642-3671
  • Fax: 712-642-4155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JEFF WALLS
Title or Position: OWNER
Credential: DDS
Phone: 712-642-3671