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General NPI Number Information
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NPI Number | 1316960131
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Entity Type | Individual
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Provider Name | KEVIN BRUCE WALLACE D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 11/02/2011
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Provider Practice Location Address
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Address Line | 949 N 14TH ST
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City | LEESBURG
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State | FL
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Zip | 34748-3838
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Country | US
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Telephone | 352-816-0855
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Fax |
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Provider Business Mailing Address
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Address Line | 1107 S.E. 24 TERRACE
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City | OCALA
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State | FL
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Zip | 34471
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Country | US
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Telephone | 352-867-9890
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Fax | 352-622-7616
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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 | DN15774
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License Number State | FL
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