Provider Demographics
NPI:1043429368
Name:WALLACE, CAROLE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-2165
Mailing Address - Country:US
Mailing Address - Phone:732-389-2454
Mailing Address - Fax:
Practice Address - Street 1:82 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1160
Practice Address - Country:US
Practice Address - Phone:732-530-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0191481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice