MEDICARE: CHARLES COLEMAN WALL DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5134366-9922	UT

General Provider Information

NPI Number	:	1376985655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES COLEMAN WALL DDS

Provider Business Mailing Address
First Line	:	2200 E 4500 S
Second Line	:	SUITE 240
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4437
Country	:	US
Telephone Number	:	801-278-3864
Fax Number	:	801-278-3868

Provider Business Practice Location Address
First Line	:	2200 E 4500 S
Second Line	:	SUITE 240
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4437
Country	:	US
Telephone Number	:	801-278-3864
Fax Number	:	801-278-3868

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2013
Last Update Date	:	07/26/2013

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