Provider Demographics
NPI:1114255569
Name:MEIKLE, WALLACE BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:BRUCE
Last Name:MEIKLE
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 1:301 E BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2803
Mailing Address - Country:US
Mailing Address - Phone:176-025-6596
Mailing Address - Fax:176-025-6185
Practice Address - Street 1:301 E BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2803
Practice Address - Country:US
Practice Address - Phone:176-025-6596
Practice Address - Fax:176-025-6185
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist