MEDICARE: DARREN K WALLACE D.M.D.

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	D-3641	ID

General Provider Information

NPI Number	:	1841305646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARREN K WALLACE D.M.D.

Provider Business Mailing Address
First Line	:	16 ARCADE UNIT 198747
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37219-1994
Country	:	US
Telephone Number	:	615-750-0343
Fax Number	:	615-986-1705

Provider Business Practice Location Address
First Line	:	2003 E QUAIL RUN RD
Second Line	:
City	:	EMMETT
State	:	ID
Zip	:	83617-5059
Country	:	US
Telephone Number	:	208-365-3534
Fax Number	:	208-365-6231

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	01/16/2014

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