MEDICARE: DR. RICHARD J WALLACE D.D.S.

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	105208	CO

General Provider Information

NPI Number	:	1972596443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD J WALLACE D.D.S.

Provider Business Mailing Address
First Line	:	20921 E SMOKY HILL ROAD
Second Line	:	SUITE A
City	:	CENTENNIAL
State	:	CO
Zip	:	80015
Country	:	US
Telephone Number	:	303-690-7778
Fax Number	:	303-690-1158

Provider Business Practice Location Address
First Line	:	20921 E SMOKY HILL RD
Second Line	:	SUITE A
City	:	CENTENNIAL
State	:	CO
Zip	:	80015
Country	:	US
Telephone Number	:	303-690-7778
Fax Number	:	303-690-1158

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	09/15/2010

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