Provider Demographics
NPI:1063528586
Name:WALL, TANYA C (DDS)
Entity type:Individual
Prefix:DR
First Name:TANYA
Middle Name:C
Last Name:WALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26948
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226
Mailing Address - Country:US
Mailing Address - Phone:904-751-5126
Mailing Address - Fax:904-751-5146
Practice Address - Street 1:2255 DUNN AVE
Practice Address - Street 2:BLDG. 700
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218
Practice Address - Country:US
Practice Address - Phone:904-751-5126
Practice Address - Fax:904-751-5146
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLDN156011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70640OtherADI HEALTHY KIDS
FL0758264000Medicaid