| NPI | 1962888636 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MATTHEW D WALL Owner 360-491-7080 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA 60048046) |
| Enumeration Date | 2015-08-05 |
| Last Update Date | 2015-08-05 |