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General NPI Number Information
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NPI Number | 1255563946
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Entity Type | Organization
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Legal Business Name | DEREK H. WALL DDS PA
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Dates
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Enumeration Date | 08/14/2009
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Last Update Date | 08/14/2009
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Provider Practice Location Address
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Address Line | 801 OHIO AVE
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City | LYNN HAVEN
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State | FL
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Zip | 32444-2351
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Country | US
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Telephone | 850-265-3696
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Fax | 850-265-2699
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Provider Business Mailing Address
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Address Line | 801 OHIO AVE
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City | LYNN HAVEN
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State | FL
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Zip | 32444-2351
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Country | US
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Telephone | 850-265-3696
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Fax | 850-265-2699
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEREK HEATH WALL DDS PA
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Credential |
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Telephone | 850-265-3696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN14056
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License Number State | FL
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