Healthcare Provider Details

I. General information

NPI: 1942342548
Provider Name (Legal Business Name): KENNETH F WALLACE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MT ZION RD SUITE D
FLORENCE KY
41042
US

IV. Provider business mailing address

PO BOX 1066
FLORENCE KY
41022-1066
US

V. Phone/Fax

Practice location:
  • Phone: 859-283-1986
  • Fax: 859-283-2586
Mailing address:
  • Phone: 859-283-1986
  • Fax: 859-283-2586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6386
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: