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General NPI Number Information
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NPI Number | 1063528586
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Entity Type | Individual
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Provider Name | TANYA C WALL DDS
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Gender | Female
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 01/08/2019
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Provider Practice Location Address
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Address Line | 2255 DUNN AVE BLDG. 700
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City | JACKSONVILLE
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State | FL
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Zip | 32218
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Country | US
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Telephone | 904-751-5126
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Fax | 904-751-5146
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Provider Business Mailing Address
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Address Line | PO BOX 26948
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City | JACKSONVILLE
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State | FL
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Zip | 32226
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Country | US
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Telephone | 904-751-5126
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Fax | 904-751-5146
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN15601
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License Number State | FL
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