Provider Demographics
NPI:1679740898
Name:WALLS FAMILY DENTISTRY, INC
Entity type:Organization
Organization Name:WALLS FAMILY DENTISTRY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-486-0039
Mailing Address - Street 1:12627 S HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-6476
Mailing Address - Country:US
Mailing Address - Phone:918-486-0039
Mailing Address - Fax:918-486-0097
Practice Address - Street 1:12627 S HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-6476
Practice Address - Country:US
Practice Address - Phone:918-486-0039
Practice Address - Fax:918-486-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK5393261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental