Provider Demographics
NPI:1205020286
Name:WALLACE, STEPHEN LEON
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEON
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:LEON
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:225 DUNBAR CAVE RD STE B
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8846
Mailing Address - Country:US
Mailing Address - Phone:931-552-5332
Mailing Address - Fax:931-552-6348
Practice Address - Street 1:225 DUNBAR CAVE RD STE B
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-8846
Practice Address - Country:US
Practice Address - Phone:931-552-5332
Practice Address - Fax:931-552-6348
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000040011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics