Provider Demographics
NPI:1356536593
Name:DAVID A. WALLACE, DDS, MS, LTD.
Entity type:Organization
Organization Name:DAVID A. WALLACE, DDS, MS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFC. MNGR.
Authorized Official - Prefix:
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-425-2611
Mailing Address - Street 1:3712 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-7017
Mailing Address - Country:US
Mailing Address - Phone:540-552-7222
Mailing Address - Fax:540-953-3096
Practice Address - Street 1:3712 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7017
Practice Address - Country:US
Practice Address - Phone:540-552-7222
Practice Address - Fax:540-953-3096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18801223S0112X
VA034401223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0138333000Medicaid
VA8000476Medicaid
WVT21823Medicare UPIN