Provider Demographics
NPI:1275770513
Name:MICHAEL P. WALLACE D.M.D., PC
Entity Type:Organization
Organization Name:MICHAEL P. WALLACE D.M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-968-0003
Mailing Address - Street 1:9225 MANCHESTER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2640
Mailing Address - Country:US
Mailing Address - Phone:314-968-0003
Mailing Address - Fax:314-968-0383
Practice Address - Street 1:9225 MANCHESTER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2640
Practice Address - Country:US
Practice Address - Phone:314-968-0003
Practice Address - Fax:314-968-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty