Provider Demographics
NPI:1962888636
Name:MATTHEW D WALL DDS MSD PLLC
Entity type:Organization
Organization Name:MATTHEW D WALL DDS MSD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:360-491-7080
Mailing Address - Street 1:5320 CORPORATE CENTER LOOP SE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5557
Mailing Address - Country:US
Mailing Address - Phone:360-491-7080
Mailing Address - Fax:360-491-7105
Practice Address - Street 1:5320 CORPORATE CENTER LOOP SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5557
Practice Address - Country:US
Practice Address - Phone:360-491-7080
Practice Address - Fax:360-491-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600480461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty