Healthcare Provider Details

I. General information

NPI: 1285744151
Provider Name (Legal Business Name): R JEFFREY WALLACE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11135 CHAPMAN HWY
SEYMOUR TN
37865-4857
US

IV. Provider business mailing address

11135 CHAPMAN HWY
SEYMOUR TN
37865-4857
US

V. Phone/Fax

Practice location:
  • Phone: 865-577-1963
  • Fax: 865-577-1014
Mailing address:
  • Phone: 865-577-1963
  • Fax: 865-577-1014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD54694
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: