Provider Demographics
NPI:1679868822
Name:WALLACE, STEPHEN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:06708-2505
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:06708-2505
Practice Address - Country:US
Practice Address - Phone:203-753-1112
Practice Address - Fax:203-573-0773
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT43831223P0300X
NY044912-11223P0300X
MADN111691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty