Provider Demographics
NPI:1114171667
Name:WALLACE, LESLIE H (DR)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:H
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 PASEO DE LAURA UNIT 63
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3721
Mailing Address - Country:US
Mailing Address - Phone:760-725-1200
Mailing Address - Fax:760-725-1267
Practice Address - Street 1:NAVAL HOSPITAL
Practice Address - Street 2:SANTA MARGARITA ROAD
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-8882
Practice Address - Fax:760-725-8882
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN88821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice