MEDICARE: DR. THOMAS GREGORY VAN DE WALLE 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	1223G0001X	General Practice Dentistry	21761	TX

General Provider Information

NPI Number	:	1801984448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS GREGORY VAN DE WALLE DDS

Provider Business Mailing Address
First Line	:	111 WILLOWS SPRINGS DR
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-6076
Country	:	US
Telephone Number	:	512-878-2540
Fax Number	:	512-878-2803

Provider Business Practice Location Address
First Line	:	111 WILLOW SPRINGS DR
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-5240
Country	:	US
Telephone Number	:	512-878-2540
Fax Number	:	512-878-2803

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	06/02/2016

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