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General NPI Number Information
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NPI Number | 1407921398
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Entity Type | Individual
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Provider Name | GERALD MAYNARD WALL D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 11/24/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1811 S RAINBOW BLVD SUITE 101
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City | LAS VEGAS
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State | NV
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Zip | 89146-0894
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Country | US
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Telephone | 702-562-5044
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Fax | 702-562-3289
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Provider Business Mailing Address
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Address Line | 1811 S RAINBOW BLVD SUITE 101
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City | LAS VEGAS
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State | NV
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Zip | 89146-0894
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Country | US
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Telephone | 702-562-5044
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Fax | 702-562-3289
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4543
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License Number State | NV
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