Provider Demographics
NPI:1952462327
Name:WALLIS, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WALLIS
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 1:3701 KIRBY DR
Mailing Address - Street 2:SUITE 550
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-3900
Mailing Address - Country:US
Mailing Address - Phone:713-797-9041
Mailing Address - Fax:
Practice Address - Street 1:8455 FANNIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-4816
Practice Address - Country:US
Practice Address - Phone:713-797-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX95601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice