=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679214035
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAMP, WALLACE & ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2022
-----------------------------------------------------
Last Update Date | 08/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 CINEMA DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-1490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-442-3443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 CINEMA DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-1490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-745-6215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | TERESA LEIGH ZWICKY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-866-8811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------