Provider Demographics
NPI:1215108220
Name:WM.HENRY WALL
Entity type:Organization
Organization Name:WM.HENRY WALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-448-0966
Mailing Address - Street 1:5139 JIMMY CARTER BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1638
Mailing Address - Country:US
Mailing Address - Phone:770-448-0966
Mailing Address - Fax:770-448-8549
Practice Address - Street 1:5139 JIMMY CARTER BLVD STE 201
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1638
Practice Address - Country:US
Practice Address - Phone:770-448-0966
Practice Address - Fax:770-448-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0068171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty