Healthcare Provider Details

I. General information

NPI: 1609528728
Provider Name (Legal Business Name): TRAX ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 WEST 3RD ST
PERRYSBURG OH
43551
US

IV. Provider business mailing address

141 WEST 3RD ST
PERRYSBURG OH
43551
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-6885
  • Fax:
Mailing address:
  • Phone: 419-690-6885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HEATH WALLACE
Title or Position: OWNER
Credential: DDS
Phone: 419-966-8006