MEDICARE: DR. LAUREN WALLACE D.M.D

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	122300000X	Dentist	6194	AL

General Provider Information

NPI Number	:	1215318241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAUREN WALLACE D.M.D

Provider Business Mailing Address
First Line	:	613 HALEY ANN DR SW
Second Line	:
City	:	HARTSELLE
State	:	AL
Zip	:	35640-3812
Country	:	US
Telephone Number	:	256-466-3131
Fax Number	:

Provider Business Practice Location Address
First Line	:	1306 14TH AVE SE
Second Line	:
City	:	DECATUR
State	:	AL
Zip	:	35601-4346
Country	:	US
Telephone Number	:	256-350-5810
Fax Number	:

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

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	06/16/2015

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