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General NPI Number Information
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NPI Number | 1457029167
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Entity Type | Individual
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Provider Name | PABLO MADRIGAL WALLE DDS
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Gender | Male
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Dates
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Enumeration Date | 08/30/2021
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Last Update Date | 10/31/2022
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Provider Practice Location Address
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Address Line | 3100 E SERVICE RD
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City | CERES
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State | CA
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Zip | 95307-6422
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Country | US
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Telephone | 209-542-9921
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Fax |
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Provider Business Mailing Address
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Address Line | 1547 CONCERTO LN # LM
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City | HUGHSON
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State | CA
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Zip | 95326-9136
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Country | US
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Telephone | 209-484-3078
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 106838
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License Number State | CA
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