Provider Demographics
NPI:1407902257
Name:WALLACE, SCOTT W (DDS)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:W
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 1:4101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELVERSON
Mailing Address - State:PA
Mailing Address - Zip Code:19520-9378
Mailing Address - Country:US
Mailing Address - Phone:610-286-5841
Mailing Address - Fax:610-286-0161
Practice Address - Street 1:4101 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9378
Practice Address - Country:US
Practice Address - Phone:610-286-5841
Practice Address - Fax:610-286-0161
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO26093L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice