Provider Demographics
NPI:1518057934
Name:DAVIS-WALLACE, DEDRA DESIREE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEDRA
Middle Name:DESIREE
Last Name:DAVIS-WALLACE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 STEIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6978
Mailing Address - Country:US
Mailing Address - Phone:715-835-7172
Mailing Address - Fax:
Practice Address - Street 1:3131 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6978
Practice Address - Country:US
Practice Address - Phone:715-835-7172
Practice Address - Fax:713-490-6464
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122721223P0221X
TX248911223P0221X
WI1001197-151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1518057934Medicaid