=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013341791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENNIS B WALL DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2013
-----------------------------------------------------
Last Update Date | 08/29/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47 PLEASANT ST
-----------------------------------------------------
City | WINCHENDON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01475-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-297-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 PLEASANT ST
-----------------------------------------------------
City | WINCHENDON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01475-1618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-297-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL DIRECTOR
-----------------------------------------------------
Name | DR. JOSEPH YAMIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 978-534-0173
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 17147
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------