Provider Demographics
NPI:1285004077
Name:THE WALLACE GROUP GENERAL DENTISTRY FOR TODAY, INC
Entity Type:Organization
Organization Name:THE WALLACE GROUP GENERAL DENTISTRY FOR TODAY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:513-531-2338
Mailing Address - Street 1:5258 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45212-1648
Mailing Address - Country:US
Mailing Address - Phone:513-531-2338
Mailing Address - Fax:
Practice Address - Street 1:5258 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:OH
Practice Address - Zip Code:45212-1648
Practice Address - Country:US
Practice Address - Phone:513-531-2338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH015533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty