Provider Demographics
NPI:1841404019
Name:KEVIN D WALLACE DMD, PC
Entity Type:Organization
Organization Name:KEVIN D WALLACE DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,PC
Authorized Official - Phone:417-881-1123
Mailing Address - Street 1:1200 E WOODHURST DR
Mailing Address - Street 2:SUITE 200-A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4257
Mailing Address - Country:US
Mailing Address - Phone:417-881-1123
Mailing Address - Fax:417-883-0812
Practice Address - Street 1:1200 E WOODHURST DR
Practice Address - Street 2:SUITE 200-A
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4257
Practice Address - Country:US
Practice Address - Phone:417-881-1123
Practice Address - Fax:417-883-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0149351223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOWA405263807Medicaid
MOU20321Medicare UPIN
MO23463Medicare ID - Type Unspecified