Provider Demographics
NPI:1114101920
Name:VAN ALSTINE, WALLACE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:L
Last Name:VAN ALSTINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 PACKARD RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1851
Mailing Address - Country:US
Mailing Address - Phone:734-482-8500
Mailing Address - Fax:734-482-5044
Practice Address - Street 1:1900 PACKARD RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1851
Practice Address - Country:US
Practice Address - Phone:734-482-8500
Practice Address - Fax:734-482-5044
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI92801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice