Healthcare Provider Details

I. General information

NPI: 1124092697
Provider Name (Legal Business Name): MARSHALL LYNN WALLACE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PROFESSIONAL CT
SUMTER SC
29150-1927
US

IV. Provider business mailing address

3 PROFESSIONAL CT
SUMTER SC
29150-1927
US

V. Phone/Fax

Practice location:
  • Phone: 803-469-9461
  • Fax: 803-469-9023
Mailing address:
  • Phone: 803-469-9461
  • Fax: 803-469-9023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2839/363
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: