Provider Demographics
NPI:1154471415
Name:THUNE, WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:THUNE
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 1:181 AVENIDA VAQUERO SUITE B
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672
Mailing Address - Country:US
Mailing Address - Phone:949-498-6840
Mailing Address - Fax:949-498-5886
Practice Address - Street 1:181 AVENIDA VAQUERO STE B
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3658
Practice Address - Country:US
Practice Address - Phone:949-498-6840
Practice Address - Fax:949-498-5886
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice