Healthcare Provider Details

I. General information

NPI: 1659542215
Provider Name (Legal Business Name): BENJAMIN EARL WALL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 05/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10894 S RIVER FRONT PKWY
SOUTH JORDAN UT
84095-5609
US

IV. Provider business mailing address

1347 E ESTRELLITA DR
SANDY UT
84093-1250
US

V. Phone/Fax

Practice location:
  • Phone: 801-878-1471
  • Fax:
Mailing address:
  • Phone: 602-785-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60118562
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8495
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8892816-9921
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN-9427
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: