Provider Demographics
NPI:1689681041
Name:WALLACE, KIM EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:EUGENE
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 1:635 ANDERSON RD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3505
Mailing Address - Country:US
Mailing Address - Phone:530-757-6453
Mailing Address - Fax:530-757-6450
Practice Address - Street 1:635 ANDERSON RD
Practice Address - Street 2:SUITE 17
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3505
Practice Address - Country:US
Practice Address - Phone:530-757-6453
Practice Address - Fax:530-757-6450
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA229321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice