Provider Demographics
NPI:1821263831
Name:LAIL, WALLACE C (DDS)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:C
Last Name:LAIL
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 1:3415 E LAWRENCEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-3354
Mailing Address - Country:US
Mailing Address - Phone:770-476-5227
Mailing Address - Fax:
Practice Address - Street 1:3415 E LAWRENCEVILLE ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-3354
Practice Address - Country:US
Practice Address - Phone:770-476-5227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA69811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice