MEDICARE: WALLACE FAMILY DENTISTRY LLC

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

General Provider Information

NPI Number	:	1649132192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	5258 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45212-1648
Country	:	US
Telephone Number	:	513-531-2338
Fax Number	:	513-841-5545

Provider Business Practice Location Address
First Line	:	5258 MONTGOMERY RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45212-1648
Country	:	US
Telephone Number	:	513-531-2338
Fax Number	:	513-841-5545

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JARED R GRAHAM
Credential	:	DDS
Telephone Number	:	513-531-2338

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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