Healthcare Provider Details

I. General information

NPI: 1497287817
Provider Name (Legal Business Name): ZACHARY D WALLACE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W INDUSTRIAL PARK RD
HARRISON AR
72601
US

IV. Provider business mailing address

127 W INDUSTRIAL PARK RD
HARRISON AR
72601-2205
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-2808
  • Fax:
Mailing address:
  • Phone: 417-209-0972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4241
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: