Provider Demographics
NPI:1942342548
Name:WALLACE, KENNETH F (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:F
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:PO BOX 1066
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41022-1066
Mailing Address - Country:US
Mailing Address - Phone:859-283-1986
Mailing Address - Fax:859-283-2586
Practice Address - Street 1:280 MT ZION RD
Practice Address - Street 2:SUITE D
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042
Practice Address - Country:US
Practice Address - Phone:859-283-1986
Practice Address - Fax:859-283-2586
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61942850Medicaid