Healthcare Provider Details

I. General information

NPI: 1841404019
Provider Name (Legal Business Name): KEVIN D WALLACE DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 08/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E WOODHURST DR SUITE 200-A
SPRINGFIELD MO
65804-4257
US

IV. Provider business mailing address

1200 E WOODHURST DR SUITE 200-A
SPRINGFIELD MO
65804-4257
US

V. Phone/Fax

Practice location:
  • Phone: 417-881-1123
  • Fax: 417-883-0812
Mailing address:
  • Phone: 417-881-1123
  • Fax: 417-883-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number014935
License Number StateMO

VIII. Authorized Official

Name: DR. KEVIN D WALLACE
Title or Position: DENTIST
Credential: D.M.D.,P.C.
Phone: 417-881-1123