Provider Demographics
NPI:1174146864
Name:WALL, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 EAST BAY DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771
Mailing Address - Country:US
Mailing Address - Phone:727-531-5100
Mailing Address - Fax:727-507-0009
Practice Address - Street 1:PINELLAS DENTAL SPECIALTIES
Practice Address - Street 2:2700 EAST BAY DRIVE, SUITE 201
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771
Practice Address - Country:US
Practice Address - Phone:727-531-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN25482261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program