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General NPI Number Information
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NPI Number | 1780712109
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Entity Type | Individual
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Provider Name | WALLACE LEE WALKER JR. DDS
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Gender | Male
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 01/08/2013
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Provider Practice Location Address
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Address Line | 2685 JOLLY RD
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City | OKEMOS
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State | MI
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Zip | 48864-3553
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Country | US
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Telephone | 517-993-5924
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Fax | 517-993-5923
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Provider Business Mailing Address
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Address Line | 17524 DORSET AVE
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City | SOUTHFIELD
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State | MI
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Zip | 48075-4215
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Country | US
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Telephone | 248-470-0822
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Fax |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 12881
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License Number State | MI
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