MEDICARE: DR. MARTHA COCHRAN WALLACE D.M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3030	AL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	510-40457	OTHER	AL	BLUE CROSS BLUE SHIELD
6	510-40458	OTHER	AL	BLUE CROSS BLUE SHIELD
7	510-40459	OTHER	AL	BLUE CROSS BLUE SHIELD
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	510-40460	OTHER	AL	BLUE CROSS BLUE SHIELD

NPI Number	:	1639172158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTHA COCHRAN WALLACE D.M.D.

Provider Business Mailing Address
First Line	:	1400 6TH AVE S
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35233-1502
Country	:	US
Telephone Number	:	205-930-1015
Fax Number	:	205-930-1448

Provider Business Practice Location Address
First Line	:	1400 6TH AVE S
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35233-1502
Country	:	US
Telephone Number	:	205-930-1015
Fax Number	:	205-930-1448

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

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	01/05/2011

1400 6TH AVE S , DENTAL HEALTH SERVICES
BIRMINGHAM, AL
35233-1502

Practice Phone: 205-930-1422
Practice Fax: 205-930-1448