Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DN15601 | FL |
NPI | 1063528586 |
---|---|
Provider Name | Dr. Tanya C Wall |
First Address | Jacksonville, FL 32226 |
Second Address | Jacksonville, FL 32218 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2006 |
Last Update Date | 08/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0758264000 | (05) | FL |
70640 | ADI HEALTHY KIDS (01) | FL |