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General NPI Number Information
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NPI Number | 1679580518
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Entity Type | Organization
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Legal Business Name | TERRACE HILL DENTAL CENTER LLC
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 10/02/2017
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Provider Practice Location Address
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Address Line | 6654 U S HIGHWAY 98
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City | HATTIESBURG
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State | MS
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Zip | 39402-7936
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Country | US
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Telephone | 601-264-5756
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Fax | 601-264-5013
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Provider Business Mailing Address
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Address Line | 6654 U S HIGHWAY 98
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City | HATTIESBURG
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State | MS
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Zip | 39402-7936
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Country | US
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Telephone | 601-264-5756
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Fax | 601-264-5013
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Authorized Official
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Title or Position | DENTIST/CO-OWNER
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Name | DR. FELDER E WALLACE
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Credential | DDS
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Telephone | 601-264-5756
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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 | 1771.77
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License Number State | MS
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