1841404019 NPI number — KEVIN D WALLACE DMD, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841404019 NPI number — KEVIN D WALLACE DMD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEVIN D WALLACE DMD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841404019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 E WOODHURST DR
Provider Second Line Business Mailing Address:
SUITE 200-A
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65804-4257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-881-1123
Provider Business Mailing Address Fax Number:
417-883-0812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 E WOODHURST DR
Provider Second Line Business Practice Location Address:
SUITE 200-A
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-4257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-881-1123
Provider Business Practice Location Address Fax Number:
417-883-0812
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
417-881-1123

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  014935 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: WA405263807 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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