Healthcare Provider Details

I. General information

NPI: 1730982869
Provider Name (Legal Business Name): JAKE PARKER WALLACH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 HIGHLAND AVE STE 210
CHESHIRE CT
06410-2583
US

IV. Provider business mailing address

68 PEPPERIDGE DR
SOUTHINGTON CT
06489-4416
US

V. Phone/Fax

Practice location:
  • Phone: 475-372-0134
  • Fax:
Mailing address:
  • Phone: 860-919-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14707
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: