Provider Demographics
NPI:1932514130
Name:WALLACE, TANNER (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 LYME RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-1207
Mailing Address - Country:US
Mailing Address - Phone:603-643-3509
Mailing Address - Fax:
Practice Address - Street 1:73 LYME RD
Practice Address - Street 2:SUITE 3
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-1207
Practice Address - Country:US
Practice Address - Phone:603-643-3509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist