Healthcare Provider Details

I. General information

NPI: 1164100855
Provider Name (Legal Business Name): MATTHEW WALLA DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3985 MAIN ST
AMHERST NY
14226-3404
US

IV. Provider business mailing address

105 SPRUCE ST
LEXINGTON KY
40507-2109
US

V. Phone/Fax

Practice location:
  • Phone: 716-832-1550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GREGORY WHITE
Title or Position: CEO
Credential: DDS
Phone: 859-533-1109