MEDICARE: ASHLEY 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	39215	TX

General Provider Information

NPI Number	:	1821796517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY WALLACE DDS

Provider Business Mailing Address
First Line	:	21626 STONEWALL PKWY APT 3312
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78256-1716
Country	:	US
Telephone Number	:	413-348-4847
Fax Number	:

Provider Business Practice Location Address
First Line	:	17122 BULVERDE RD STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-3211
Country	:	US
Telephone Number	:	210-495-2000
Fax Number	:

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

Provider Enumeration Date	:	02/21/2023
Last Update Date	:	02/21/2023

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