Provider Demographics
NPI:1336571785
Name:WALLACE FOOT AND ANKLE CENTER, PLLC
Entity Type:Organization
Organization Name:WALLACE FOOT AND ANKLE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENTON
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-446-8290
Mailing Address - Street 1:608 NW 9TH ST
Mailing Address - Street 2:SUITE 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:
Practice Address - Street 1:608 NW 9TH ST
Practice Address - Street 2:SUITE 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK292213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200341570AMedicare PIN