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General NPI Number Information
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NPI Number | 1215318241
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Entity Type | Individual
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Provider Name | LAUREN WALLACE D.M.D
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Gender | Female
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Dates
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Enumeration Date | 06/16/2015
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Last Update Date | 06/16/2015
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Provider Practice Location Address
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Address Line | 1306 14TH AVE SE
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City | DECATUR
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State | AL
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Zip | 35601-4346
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Country | US
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Telephone | 256-350-5810
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Fax |
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Provider Business Mailing Address
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Address Line | 613 HALEY ANN DR SW
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City | HARTSELLE
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State | AL
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Zip | 35640-3812
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Country | US
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Telephone | 256-466-3131
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 6194
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License Number State | AL
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