Healthcare Provider Details

I. General information

NPI: 1306358312
Provider Name (Legal Business Name): CHERYL WALLACE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHERYL LYNN WALLACE RDH

II. Dates (important events)

Enumeration Date: 10/31/2017
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 E VAN BUREN ST
PHOENIX AZ
85008-6920
US

IV. Provider business mailing address

3003 N CENTRAL AVE STE 1600
PHOENIX AZ
85012-2908
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-7277
  • Fax:
Mailing address:
  • Phone: 602-323-3344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH009325
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: