Healthcare Provider Details

I. General information

NPI: 1972750909
Provider Name (Legal Business Name): KEVIN D WALLACE DMD PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

1200 E WOODHURST DR STE A200
SPRINGFIELD MO
65804-3745
US

IV. Provider business mailing address

1200 E WOODHURST DR STE A200
SPRINGFIELD MO
65804-3745
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:
Title or Position:
Credential:
Phone: