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NPI Code Detail

MEDICARE: CHERYL WALLACE RDH

MEDICARE: CHERYL WALLACE RDH
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
1124Q00000XDental HygienistH009325AZ

General Provider Information

NPI Number : 1306358312
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHERYL WALLACE RDH
Provider Business Mailing Address
First Line : 3003 N CENTRAL AVE STE 1600
Second Line :
City : PHOENIX
State : AZ
Zip : 85012-2908
Country : US
Telephone Number : 602-323-3344
Fax Number :
Provider Business Practice Location Address
First Line : 3830 E VAN BUREN ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85008-6920
Country : US
Telephone Number : 602-243-7277
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/31/2017
Last Update Date : 05/07/2026

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