Provider Demographics
NPI:1629348198
Name:WALLACE, TABITHA A (RDH)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:A
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12921 CANTRELL ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-1798
Mailing Address - Country:US
Mailing Address - Phone:501-664-3279
Mailing Address - Fax:501-664-5392
Practice Address - Street 1:12921 CANTRELL ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-1798
Practice Address - Country:US
Practice Address - Phone:501-664-3279
Practice Address - Fax:501-664-5392
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2217124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist