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General NPI Number Information
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NPI Number | 1841404019
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Entity Type | Organization
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Legal Business Name | KEVIN D WALLACE DMD, PC
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Dates
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Enumeration Date | 05/09/2007
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Last Update Date | 08/21/2008
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Provider Practice Location Address
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Address Line | 1200 E WOODHURST DR SUITE 200-A
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City | SPRINGFIELD
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State | MO
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Zip | 65804-4257
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Country | US
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Telephone | 417-881-1123
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Fax | 417-883-0812
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Provider Business Mailing Address
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Address Line | 1200 E WOODHURST DR SUITE 200-A
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City | SPRINGFIELD
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State | MO
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Zip | 65804-4257
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Country | US
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Telephone | 417-881-1123
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Fax | 417-883-0812
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KEVIN D WALLACE
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Credential | D.M.D.,P.C.
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Telephone | 417-881-1123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 014935
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License Number State | MO
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