Provider Demographics
NPI:1306060306
Name:CHARLES C WALL DDS
Entity type:Organization
Organization Name:CHARLES C WALL DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-278-3864
Mailing Address - Street 1:2200 EAST 4500 SOUTH
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117
Mailing Address - Country:US
Mailing Address - Phone:801-278-3864
Mailing Address - Fax:801-278-3868
Practice Address - Street 1:2200 EAST 4500 SOUTH
Practice Address - Street 2:SUITE 240
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117
Practice Address - Country:US
Practice Address - Phone:801-278-3864
Practice Address - Fax:801-278-3868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT513436699221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty