Provider Demographics
NPI:1073907960
Name:WALLACE, SHERNIQUE (DDS)
Entity Type:Individual
Prefix:
First Name:SHERNIQUE
Middle Name:
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 1:807 S POST OAK LN APT 1416
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-2268
Mailing Address - Country:US
Mailing Address - Phone:718-724-4869
Mailing Address - Fax:
Practice Address - Street 1:8330 LONG POINT RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055
Practice Address - Country:US
Practice Address - Phone:713-461-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059085-1390200000X
NY390200000X
TX338491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program