MEDICARE: WALLACE FOOT AND ANKLE CENTER, PLLC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	292	OK

General Provider Information

NPI Number	:	1336571785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE FOOT AND ANKLE CENTER, PLLC

Provider Business Mailing Address
First Line	:	608 NW 9TH ST
Second Line	:	SUITE 4210
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1068
Country	:	US
Telephone Number	:	405-446-8290
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 NW 9TH ST
Second Line	:	SUITE 4210
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1068
Country	:	US
Telephone Number	:	405-446-8290
Fax Number	:

Authorized Official
Title or Position	:	PODIATRIST
Name	:	DR. TRENTON DALE WALLACE
Credential	:	DPM
Telephone Number	:	405-446-8290

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	06/23/2016

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