Provider Demographics
NPI:1932346897
Name:WALL, MICHAEL VINCENT (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VINCENT
Last Name:WALL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8151 E INDIAN BEND RD
Mailing Address - Street 2:STE 111
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-4826
Mailing Address - Country:US
Mailing Address - Phone:407-680-9999
Mailing Address - Fax:
Practice Address - Street 1:3552 W GLENDALE AVE
Practice Address - Street 2:STE. B
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-8358
Practice Address - Country:US
Practice Address - Phone:602-888-7844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57415122300000X
AZ8394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist