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General NPI Number Information
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NPI Number | 1285004077
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Entity Type | Organization
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Legal Business Name | THE WALLACE GROUP GENERAL DENTISTRY FOR TODAY, INC
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Dates
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Enumeration Date | 10/06/2015
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Last Update Date | 10/06/2015
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Provider Practice Location Address
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Address Line | 5258 MONTGOMERY RD
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City | NORWOOD
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State | OH
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Zip | 45212-1648
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Country | US
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Telephone | 513-531-2338
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Fax |
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Provider Business Mailing Address
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Address Line | 5258 MONTGOMERY RD
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City | NORWOOD
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State | OH
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Zip | 45212-1648
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Country | US
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Telephone | 513-531-2338
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WILLIAM R WALLACE
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Credential | DDS
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Telephone | 513-531-2338
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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 | 015533
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License Number State | OH
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