MEDICARE: DR. MICHAEL VINCENT WALL D.D.S.

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	57415	CA
2	122300000X	Dentist	8394	AZ

General Provider Information

NPI Number	:	1932346897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL VINCENT WALL D.D.S.

Provider Business Mailing Address
First Line	:	8151 E INDIAN BEND RD
Second Line	:	STE 111
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85250-4826
Country	:	US
Telephone Number	:	407-680-9999
Fax Number	:

Provider Business Practice Location Address
First Line	:	3552 W GLENDALE AVE
Second Line	:	STE. B
City	:	PHOENIX
State	:	AZ
Zip	:	85051-8358
Country	:	US
Telephone Number	:	602-888-7844
Fax Number	:

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

Provider Enumeration Date	:	01/14/2009
Last Update Date	:	09/22/2016

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