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General NPI Number Information
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NPI Number | 1245127331
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Entity Type | Individual
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Provider Name | MARY C WALLACE DDS
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Gender | Female
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Dates
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Enumeration Date | 06/20/2025
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Last Update Date | 08/19/2025
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Provider Practice Location Address
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Address Line | 5540 OLD JACKSONVILLE HWY
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City | TYLER
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State | TX
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Zip | 75703-3378
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Country | US
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Telephone | 903-597-2121
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Fax |
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Provider Business Mailing Address
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Address Line | 4055 HOGAN DR APT 3707
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City | TYLER
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State | TX
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Zip | 75709-6964
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Country | US
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Telephone | 903-805-9767
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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 | 41468
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License Number State | TX
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