Healthcare Provider Details

I. General information

NPI: 1386646206
Provider Name (Legal Business Name): DAVID ALLEN WALLACE DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S WALKER ST
PRINCETON WV
24740-2747
US

IV. Provider business mailing address

206 S WALKER ST
PRINCETON WV
24740-2747
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-2611
  • Fax:
Mailing address:
  • Phone: 304-425-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1880
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0401003440
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: