Provider Demographics
NPI:1629121561
Name:STEPHEN WALLACE DDS PC
Entity Type:Organization
Organization Name:STEPHEN WALLACE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CATHCART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-753-1112
Mailing Address - Street 1:140 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-753-1112
Mailing Address - Fax:203-573-0773
Practice Address - Street 1:140 GRANDVIEW AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-753-1112
Practice Address - Fax:203-573-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT43831223P0300X
NY044912-11223P0300X
MADN111691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty