Provider Demographics
NPI:1194940924
Name:WALL, MICHAEL JAMES (DMD MS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:WALL
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:45 1048 KAM HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744
Mailing Address - Country:US
Mailing Address - Phone:808-235-6801
Mailing Address - Fax:
Practice Address - Street 1:45 1048 KAM HWY
Practice Address - Street 2:SUITE B
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744
Practice Address - Country:US
Practice Address - Phone:808-235-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT12571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics