Provider Demographics
NPI:1962535625
Name:SAND WALL, DARLENE (DMD)
Entity type:Individual
Prefix:DR
First Name:DARLENE
Middle Name:
Last Name:SAND WALL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 CENTRE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3409
Mailing Address - Country:US
Mailing Address - Phone:859-344-8500
Mailing Address - Fax:859-344-8506
Practice Address - Street 1:465 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3409
Practice Address - Country:US
Practice Address - Phone:859-344-8500
Practice Address - Fax:859-344-8506
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY63321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice