Healthcare Provider Details

I. General information

NPI: 1205624749
Provider Name (Legal Business Name): WALLACE J BELLAMY DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8007 LAGUNA BLVD SUITE 3
ELK GROVE CA
95758
US

IV. Provider business mailing address

4170 TRUXEL ROAD SUITE C
SACRAMENTO CA
95834
US

V. Phone/Fax

Practice location:
  • Phone: 916-683-3011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JAGDEV HEIR
Title or Position: CEO/PRESIDENT
Credential:
Phone: 518-441-5483