Provider Demographics
NPI:1548214034
Name:NANCY S. WALLACE, D.M.D., LTD.
Entity Type:Organization
Organization Name:NANCY S. WALLACE, D.M.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-662-6080
Mailing Address - Street 1:1709 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5133
Mailing Address - Country:US
Mailing Address - Phone:847-662-6080
Mailing Address - Fax:847-662-6086
Practice Address - Street 1:1709 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5133
Practice Address - Country:US
Practice Address - Phone:847-662-6080
Practice Address - Fax:847-662-6086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty