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General NPI Number Information
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NPI Number | 1629121561
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Entity Type | Organization
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Legal Business Name | STEPHEN WALLACE DDS PC
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 03/22/2012
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Provider Practice Location Address
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Address Line | 140 GRANDVIEW AVE SUITE 102
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City | WATERBURY
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State | CT
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Zip | 06708
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Country | US
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Telephone | 203-753-1112
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Fax | 203-573-0773
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Provider Business Mailing Address
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Address Line | 140 GRANDVIEW AVE SUITE 102
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City | WATERBURY
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State | CT
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Zip | 06708
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Country | US
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Telephone | 203-753-1112
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Fax | 203-573-0773
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. JENNIFER M CATHCART
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Credential |
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Telephone | 203-753-1112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 044912-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN11169
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 4383
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License Number State | CT
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