Provider Demographics
NPI:1548426851
Name:RALLISON, M. WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:WADE
Last Name:RALLISON
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 1:5275 S. ADAMS AVE., SUITE C
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TERRACE
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-475-6433
Mailing Address - Fax:
Practice Address - Street 1:5275 S. ADAMS AVE., SUITE C
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-475-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5118697-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$002Medicaid