Provider Demographics
NPI:1528371507
Name:WALLIS, JEFFREY SAMUEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SAMUEL
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 W ORMOND AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-3041
Mailing Address - Country:US
Mailing Address - Phone:856-428-4445
Mailing Address - Fax:856-428-4497
Practice Address - Street 1:17 W ORMOND AVE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3041
Practice Address - Country:US
Practice Address - Phone:856-428-4445
Practice Address - Fax:856-428-4497
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0381601223S0112X
NJ22DI025713001223S0112X
NJ22DI025713011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery