Provider Demographics
NPI:1508857053
Name:WALLACE, PATRICK L (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 108816
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8816
Mailing Address - Country:US
Mailing Address - Phone:405-848-7974
Mailing Address - Fax:405-848-0033
Practice Address - Street 1:1119 WALNUT DR
Practice Address - Street 2:SUITE 2
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2360
Practice Address - Country:US
Practice Address - Phone:580-226-1727
Practice Address - Fax:580-226-9413
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK49881223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100119640AMedicaid
OKU51106Medicare UPIN
OK100119640AMedicaid