Provider Demographics
NPI:1093569204
Name:WALLACE, BRANDON TOBIAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:TOBIAS
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 HARRISON AVE PH 19
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4095
Mailing Address - Country:US
Mailing Address - Phone:910-580-5699
Mailing Address - Fax:
Practice Address - Street 1:4605 E GALBRAITH RD STE 100
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2888
Practice Address - Country:US
Practice Address - Phone:513-961-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program