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General NPI Number Information
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NPI Number | 1174665277
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Entity Type | Individual
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Provider Name | ERIC H WALLACE D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 02/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 28 SE 6TH ST
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City | BOCA RATON
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State | FL
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Zip | 33432-6016
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Country | US
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Telephone | 561-391-0020
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Fax | 561-391-8863
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Provider Business Mailing Address
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Address Line | 1140 SW 21ST LN
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City | BOCA RATON
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State | FL
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Zip | 33486-6722
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Country | US
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Telephone | 561-393-6385
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN0008299
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License Number State | FL
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