=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164794491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM H. WALLS, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2012
-----------------------------------------------------
Last Update Date | 02/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 656 INDEPENDENCE PKWY SUITE 210
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-548-1919
-----------------------------------------------------
Fax | 757-548-4492
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 656 INDEPENDENCE PKWY SUITE 210
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-548-1919
-----------------------------------------------------
Fax | 757-548-4492
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM HARVEY WALLS JR.
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 757-548-1919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0401007229
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------