=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962888636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTHEW D WALL DDS MSD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2015
-----------------------------------------------------
Last Update Date | 08/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5320 CORPORATE CENTER LOOP SE STE A
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-5557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-491-7080
-----------------------------------------------------
Fax | 360-491-7105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5320 CORPORATE CENTER LOOP SE STE A
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-5557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-491-7080
-----------------------------------------------------
Fax | 360-491-7105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW D WALL
-----------------------------------------------------
Credential | DDS MSD
-----------------------------------------------------
Telephone | 360-491-7080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 60048046
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------