MEDICARE: DR. MATT WALLACE

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	48566	CA

General Provider Information

NPI Number	:	1437113479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATT WALLACE

Provider Business Mailing Address
First Line	:	9290 TELEPHONE RD
Second Line	:
City	:	VENTURA
State	:	CA
Zip	:	93004-2601
Country	:	US
Telephone Number	:	805-671-9697
Fax Number	:

Provider Business Practice Location Address
First Line	:	9290 TELEPHONE RD
Second Line	:
City	:	VENTURA
State	:	CA
Zip	:	93004-2601
Country	:	US
Telephone Number	:	805-671-9697
Fax Number	:

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	07/08/2007

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