Provider Demographics
NPI:1154569424
Name:WALL, EDWARD HUGH (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HUGH
Last Name:WALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:549 SOUTH MAIN ST
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-0016
Mailing Address - Country:US
Mailing Address - Phone:706-865-2248
Mailing Address - Fax:706-219-2051
Practice Address - Street 1:549 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1411
Practice Address - Country:US
Practice Address - Phone:706-865-2248
Practice Address - Fax:706-219-2051
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN011027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist