Provider Demographics
NPI:1578564720
Name:WALLACE, ROBERT EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:E
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:425 APPERSON DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7026
Mailing Address - Country:US
Mailing Address - Phone:540-387-5817
Mailing Address - Fax:
Practice Address - Street 1:425 APPERSON DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7026
Practice Address - Country:US
Practice Address - Phone:540-387-5817
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010034421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice