Provider Demographics
NPI:1174665277
Name:WALLACE, ERIC H (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:H
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 1:1140 SW 21ST LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-6722
Mailing Address - Country:US
Mailing Address - Phone:561-393-6385
Mailing Address - Fax:
Practice Address - Street 1:28 SE 6TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-6016
Practice Address - Country:US
Practice Address - Phone:561-391-0020
Practice Address - Fax:561-391-8863
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00082991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice