MEDICARE: DR. DAWN SPRUILL WALLACE DDS

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	1223G0001X	General Practice Dentistry	7191	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7191	OTHER	NC	NC LICENSE

General Provider Information

NPI Number	:	1093814535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAWN SPRUILL WALLACE DDS

Provider Business Mailing Address
First Line	:	8401 UNIVERSITY EXECUTIVE PARKWAY
Second Line	:	SUITE 110
City	:	CHARLOTTE
State	:	NC
Zip	:	28262
Country	:	US
Telephone Number	:	704-547-1970
Fax Number	:	704-547-1926

Provider Business Practice Location Address
First Line	:	8401 UNIVERSITY EXECUTIVE DRIVE
Second Line	:	SUITE 110
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1360
Country	:	US
Telephone Number	:	704-547-1970
Fax Number	:	704-547-1926

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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