Provider Demographics
NPI:1518094598
Name:WALLACE, JOHN BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRIAN
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 1:3551 FARQUHAR AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2003
Mailing Address - Country:US
Mailing Address - Phone:562-598-4111
Mailing Address - Fax:
Practice Address - Street 1:3551 FARQUHAR AVE STE 102
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2003
Practice Address - Country:US
Practice Address - Phone:562-598-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice