Provider Demographics
NPI:1417014424
Name:WALLACE, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E DANFORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6622
Mailing Address - Country:US
Mailing Address - Phone:405-340-0411
Mailing Address - Fax:405-340-3217
Practice Address - Street 1:1617 E DANFORTH RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3103
Practice Address - Country:US
Practice Address - Phone:405-340-0411
Practice Address - Fax:405-340-3217
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5801122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200066490 AMedicaid