Provider Demographics
NPI:1447267109
Name:WALLS, RICHARDD D (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARDD
Middle Name:D
Last Name:WALLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2155 POST OAK TRITT RD
Mailing Address - Street 2:#500
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062
Mailing Address - Country:US
Mailing Address - Phone:770-973-1738
Mailing Address - Fax:770-971-9407
Practice Address - Street 1:2155 POST OAK TRITT RD
Practice Address - Street 2:#500
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:770-973-1738
Practice Address - Fax:770-971-9407
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA19NCBCZMedicare ID - Type Unspecified
U25497Medicare UPIN