Healthcare Provider Details

I. General information

NPI: 1750570107
Provider Name (Legal Business Name): VICTOR F. WALLACE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 PUEBLO TRL
MALVERN OH
44644-9528
US

IV. Provider business mailing address

31 PUEBLO TRL
MALVERN OH
44644-9528
US

V. Phone/Fax

Practice location:
  • Phone: 330-863-4055
  • Fax: 330-863-4055
Mailing address:
  • Phone: 330-863-4055
  • Fax: 330-863-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15927
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: