Provider Demographics
NPI:1629301833
Name:WALLACE, LESLIE SUZANNE (DMD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:SUZANNE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:SUZANNE
Other - Last Name:PARHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:179 COBBLER CIR
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3963
Mailing Address - Country:US
Mailing Address - Phone:859-948-0386
Mailing Address - Fax:
Practice Address - Street 1:103 PHYSICIANS WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-4104
Practice Address - Country:US
Practice Address - Phone:859-948-0386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN89731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry