Provider Demographics
NPI:1114949740
Name:ERNST, WALLACE JEFFREY (DDS)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:JEFFREY
Last Name:ERNST
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:PO BOX 99
Mailing Address - Street 2:106 W 5TH STREET
Mailing Address - City:RICEVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50466
Mailing Address - Country:US
Mailing Address - Phone:641-985-2555
Mailing Address - Fax:641-985-4918
Practice Address - Street 1:106 W 5TH STREET
Practice Address - Street 2:
Practice Address - City:RICEVILLE
Practice Address - State:IA
Practice Address - Zip Code:50466
Practice Address - Country:US
Practice Address - Phone:641-985-2555
Practice Address - Fax:641-985-2918
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA70591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22772OtherBCBS
IA1227736Medicaid