Healthcare Provider Details

I. General information

NPI: 1811978349
Provider Name (Legal Business Name): JOHN DAVID WALLACE DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8315 WALNUT HILL LN STE 120
DALLAS TX
75231-4218
US

IV. Provider business mailing address

8315 WALNUT HILL LN STE 120
DALLAS TX
75231-4218
US

V. Phone/Fax

Practice location:
  • Phone: 214-363-9946
  • Fax: 214-389-1953
Mailing address:
  • Phone: 214-363-9946
  • Fax: 214-389-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19862
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: