Healthcare Provider Details

I. General information

NPI: 1649132192
Provider Name (Legal Business Name): WALLACE FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5258 MONTGOMERY RD
CINCINNATI OH
45212-1648
US

IV. Provider business mailing address

5258 MONTGOMERY RD
CINCINNATI OH
45212-1648
US

V. Phone/Fax

Practice location:
  • Phone: 513-531-2338
  • Fax: 513-841-5545
Mailing address:
  • Phone: 513-531-2338
  • Fax: 513-841-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: JARED R GRAHAM
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 513-531-2338