Healthcare Provider Details

I. General information

NPI: 1427195254
Provider Name (Legal Business Name): WALLACE TAYLOR VANNORTWICK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7942 GOODWOOD BLVD
BATON ROUGE LA
70806-7629
US

IV. Provider business mailing address

7942 GOODWOOD BLVD
BATON ROUGE LA
70806-7629
US

V. Phone/Fax

Practice location:
  • Phone: 225-925-1517
  • Fax:
Mailing address:
  • Phone: 225-925-1517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number3211
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN 8075
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: