MEDICARE: DR. KEVIN R WALLACE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019022339	IL
2	122300000X	Dentist	019-022339	IL
3	1223G0001X	General Practice Dentistry	019022339	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1053431981	OTHER	IL	GROUP TYPE II NPI
2	1306177241	OTHER	IL	PRACTICE LOCATION TYPE II NPI
3	1205145554	OTHER	IL	PRACTICE LOCATION TYPE II NPI
4	1508198474	OTHER	IL	PRACTICE LOCATION TYPE II NPI
5	1760882005	OTHER	IL	PRACTICE LOCATION TYPE II NPI
6	1295165439	OTHER	IL	PRACTICE LOCATION TYPE II NPI
7	019-022339	OTHER	IL	DENTAL-IL
8	1063649770	OTHER	IL	GROUP TYPE II NPI

General Provider Information

NPI Number	:	1053423285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN R WALLACE DMD

Provider Business Mailing Address
First Line	:	14831 W 159TH ST STE 1
Second Line	:
City	:	LOCKPORT
State	:	IL
Zip	:	60491-9008
Country	:	US
Telephone Number	:	630-324-5369
Fax Number	:	815-744-7059

Provider Business Practice Location Address
First Line	:	150 E HURON ST
Second Line	:	STE 1103
City	:	CHICAGO
State	:	IL
Zip	:	60611
Country	:	US
Telephone Number	:	312-676-9893
Fax Number	:	815-744-7059

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	01/19/2021

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