=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265678510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NATHAN WALLS DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2008
-----------------------------------------------------
Last Update Date | 12/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 328 MAIN ST W
-----------------------------------------------------
City | RIPLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25271-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-372-4009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 328 MAIN ST W
-----------------------------------------------------
City | RIPLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25271-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. NATHAN P WALLS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 304-372-4009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3580
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------