Healthcare Provider Details

I. General information

NPI: 1699741777
Provider Name (Legal Business Name): DENNIS JAYE WALLACE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: DENNIS J WALLACE OD

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

662 EAST VISALIA ROAD
FARMERSVILLE CA
93223
US

IV. Provider business mailing address

662 EAST VISALIA ROAD PO BOX 475
FARMERSVILLE CA
93223-0475
US

V. Phone/Fax

Practice location:
  • Phone: 559-747-3461
  • Fax: 559-594-4059
Mailing address:
  • Phone: 559-747-3461
  • Fax: 559-594-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT5964 TPA
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number406OPT TPA
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00001112
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: