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General NPI Number Information
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NPI Number | 1679740898
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Entity Type | Organization
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Legal Business Name | WALLS FAMILY DENTISTRY, INC
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 03/30/2009
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Provider Practice Location Address
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Address Line | 12627 S HIGHWAY 51
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City | COWETA
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State | OK
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Zip | 74429-6476
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Country | US
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Telephone | 918-486-0039
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Fax | 918-486-0097
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Provider Business Mailing Address
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Address Line | 12627 S HIGHWAY 51
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City | COWETA
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State | OK
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Zip | 74429-6476
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Country | US
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Telephone | 918-486-0039
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Fax | 918-486-0097
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. MATTHEW WALLS
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Credential | DDS
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Telephone | 918-486-0039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | OK5393
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License Number State | OK
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