MEDICARE: DR. FAITH WALLACE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	40437	TX

General Provider Information

NPI Number	:	1134959471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FAITH WALLACE DDS

Provider Business Mailing Address
First Line	:	674 BLVD DE FRANCE
Second Line	:
City	:	PORT ROYAL
State	:	SC
Zip	:	29902
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	674 BLVD DE FRANCE
Second Line	:
City	:	PORT ROYAL
State	:	SC
Zip	:	29902
Country	:	US
Telephone Number	:	214-794-5525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2024
Last Update Date	:	08/02/2024

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