Provider Demographics
NPI:1437291200
Name:WALLACE, ROY T (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:T
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 1:655 BOSTON RD STE 3A
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-5338
Mailing Address - Country:US
Mailing Address - Phone:978-667-0691
Mailing Address - Fax:
Practice Address - Street 1:655 BOSTON RD STE 3A
Practice Address - Street 2:
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821-5338
Practice Address - Country:US
Practice Address - Phone:978-667-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA134031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice