Provider Demographics
NPI:1093143745
Name:WALLACE, WILLIAM DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DEAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 W 4170 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-1364
Mailing Address - Country:US
Mailing Address - Phone:801-260-6015
Mailing Address - Fax:
Practice Address - Street 1:747 W 4170 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-1364
Practice Address - Country:US
Practice Address - Phone:801-260-6015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT168418-1205207ZI0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathology