Provider Demographics
NPI:1093740250
Name:WALLACE, KATHRINE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:KATHRINE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2292
Mailing Address - Country:US
Mailing Address - Phone:801-292-0733
Mailing Address - Fax:801-298-5336
Practice Address - Street 1:281 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2292
Practice Address - Country:US
Practice Address - Phone:801-292-0733
Practice Address - Fax:801-298-5336
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1082790701124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist