Healthcare Provider Details

I. General information

NPI: 1467846824
Provider Name (Legal Business Name): WALLACE SIGMON MCLAURIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 PIEDMONT AVE
CINCINNATI OH
45219
US

IV. Provider business mailing address

2830 VICTORY PKWY
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8783
  • Fax: 513-475-7698
Mailing address:
  • Phone: 513-475-8783
  • Fax: 513-475-7698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number30.025891
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: