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General NPI Number Information
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NPI Number | 1104090067
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Entity Type | Organization
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Legal Business Name | JESSERWALLDDSPA
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 1045 MAIN ST SUITE 6
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City | DANVILLE
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State | VA
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Zip | 24541-1800
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Country | US
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Telephone | 434-792-8622
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Fax |
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Provider Business Mailing Address
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Address Line | 1045 MAIN ST SUITE 6
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City | DANVILLE
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State | VA
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Zip | 24541-1800
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Country | US
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Telephone | 434-792-8622
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JESSE WALL
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Credential | DDS
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Telephone | 434-792-1512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5098
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License Number State | VA
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