Provider Demographics
NPI:1508014176
Name:WALLACE, FELDER E (DDS)
Entity Type:Individual
Prefix:
First Name:FELDER
Middle Name:E
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 1:6194 HWY 98 WEST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-264-5756
Mailing Address - Fax:601-264-5013
Practice Address - Street 1:6194 HWY 98 WEST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-264-5756
Practice Address - Fax:601-264-5013
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1771-771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice