Provider Demographics
NPI:1356535314
Name:JOHN D. WALLACE, DDS, MD, PA
Entity type:Organization
Organization Name:JOHN D. WALLACE, DDS, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:214-334-7722
Mailing Address - Street 1:8315 WALNUT HILL LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4218
Mailing Address - Country:US
Mailing Address - Phone:214-363-9946
Mailing Address - Fax:214-389-1953
Practice Address - Street 1:8315 WALNUT HILL LN STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4218
Practice Address - Country:US
Practice Address - Phone:214-363-9946
Practice Address - Fax:214-389-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175945801Medicaid