MEDICARE: DR. ERIC MICHAEL 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	52016	CA

General Provider Information

NPI Number	:	1891838991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC MICHAEL WALLACE DDS

Provider Business Mailing Address
First Line	:	1515 STATE ST
Second Line	:	SUITE 9
City	:	SANTA BARBARA
State	:	CA
Zip	:	93101-2536
Country	:	US
Telephone Number	:	805-962-7933
Fax Number	:	805-962-7234

Provider Business Practice Location Address
First Line	:	1515 STATE ST
Second Line	:	SUITE 9
City	:	SANTA BARBARA
State	:	CA
Zip	:	93101-2536
Country	:	US
Telephone Number	:	805-962-7933
Fax Number	:	805-962-7234

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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