Healthcare Provider Details

I. General information

NPI: 1023931078
Provider Name (Legal Business Name): JERMAINE MICHAEL WALLS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 W LAKE MEAD PKWY STE 100
HENDERSON NV
89015-7287
US

IV. Provider business mailing address

3660 SAINT ROSE PKWY UNIT 33106
HENDERSON NV
89052-4876
US

V. Phone/Fax

Practice location:
  • Phone: 702-464-3158
  • Fax: 702-464-3158
Mailing address:
  • Phone: 773-979-5423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8447
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: