Provider Demographics
NPI:1861633539
Name:WALLACE, TRENTON
Entity Type:Individual
Prefix:DR
First Name:TRENTON
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 NW 9TH ST
Mailing Address - Street 2:#4210
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1068
Mailing Address - Country:US
Mailing Address - Phone:405-446-8290
Mailing Address - Fax:405-601-8298
Practice Address - Street 1:608 NW 9TH ST
Practice Address - Street 2:#4210
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1068
Practice Address - Country:US
Practice Address - Phone:405-446-8290
Practice Address - Fax:405-601-8298
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK292213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery