Provider Demographics
NPI:1750458402
Name:WALLACE, RICHARD DEAN (LICAC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:DEAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LICAC
Other - Prefix:MR
Other - First Name:RICHARD
Other - Middle Name:DEAN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:914 13TH AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-761-3767
Mailing Address - Fax:406-761-3038
Practice Address - Street 1:914 13TH AVE SOUTH
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-761-3767
Practice Address - Fax:406-761-3038
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT450133N00000X, 133V00000X
MT162171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered171100000XOther Service ProvidersAcupuncturist