Provider Demographics
NPI:1699878264
Name:WALL, JAMES PHILIP SR (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PHILIP
Last Name:WALL
Suffix:SR
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 1:754 COUNTRY WAY
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-1825
Mailing Address - Country:US
Mailing Address - Phone:781-545-4181
Mailing Address - Fax:781-545-3928
Practice Address - Street 1:754 COUNTRY WAY
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-1825
Practice Address - Country:US
Practice Address - Phone:781-545-4181
Practice Address - Fax:781-545-3928
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA144451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX08245WAOtherBCBS
MA0014445OtherDELTA DENTAL