Provider Demographics
NPI:1164733762
Name:WALLACE, SARAH ADE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ADE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:SARAH
Other - Middle Name:LYNN
Other - Last Name:ADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7017 JOHN DEERE PARKWAY- SUITE 2B
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-792-0513
Mailing Address - Fax:309-792-0534
Practice Address - Street 1:7017 JOHN DEERE PARKWAY - SUITE 2B
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-792-0513
Practice Address - Fax:309-792-0534
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190283571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery