Provider Demographics
NPI:1598087900
Name:WALLACE, MARQUITA DIANE
Entity Type:Individual
Prefix:MS
First Name:MARQUITA
Middle Name:DIANE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N HIGHWAY 190
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-5003
Mailing Address - Country:US
Mailing Address - Phone:615-887-1379
Mailing Address - Fax:
Practice Address - Street 1:600 N HIGHWAY 190
Practice Address - Street 2:SUITE 4
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5003
Practice Address - Country:US
Practice Address - Phone:615-887-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6135122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist