=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043486962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. LAWRENCE NORMAN WALLACE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2008
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 MIDDLE CANYON RD
-----------------------------------------------------
City | CARMEL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93924-9404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-659-9300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 MIDDLE CANYON RD
-----------------------------------------------------
City | CARMEL VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93924-9404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-659-9300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 21-770
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------