Provider Demographics
NPI:1154460459
Name:WALLACE, WAYNE CARROLL (DDS)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:CARROLL
Last Name:WALLACE
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 1:3972 RED BANK RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3425
Mailing Address - Country:US
Mailing Address - Phone:513-561-9900
Mailing Address - Fax:513-561-9902
Practice Address - Street 1:3972 RED BANK RD
Practice Address - Street 2:SUITE E
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-3425
Practice Address - Country:US
Practice Address - Phone:513-561-9900
Practice Address - Fax:513-561-9902
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH190981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0815854Medicaid