Provider Demographics
NPI:1295864304
Name:WALLACE, DONALD MCQUIRE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:MCQUIRE
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 1:3700 OLD FOREST RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-6900
Mailing Address - Country:US
Mailing Address - Phone:434-385-9454
Mailing Address - Fax:434-385-7681
Practice Address - Street 1:3700 OLD FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6900
Practice Address - Country:US
Practice Address - Phone:434-385-9454
Practice Address - Fax:434-385-7681
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401004509122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist