Provider Demographics
NPI:1639172158
Name:WALLACE, MARTHA COCHRAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:COCHRAN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1502
Mailing Address - Country:US
Mailing Address - Phone:205-930-1015
Mailing Address - Fax:205-930-1448
Practice Address - Street 1:1400 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1502
Practice Address - Country:US
Practice Address - Phone:205-930-1015
Practice Address - Fax:205-930-1448
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL103678Medicaid
AL103676Medicaid
AL1639172158Medicaid
AL103546Medicaid
AL510-40457OtherBLUE CROSS BLUE SHIELD
AL510-40458OtherBLUE CROSS BLUE SHIELD
AL510-40459OtherBLUE CROSS BLUE SHIELD
AL103578Medicaid
AL510-40460OtherBLUE CROSS BLUE SHIELD