Provider Demographics
NPI:1669779732
Name:WALLACE, GLYNIS DYNEL (DMD)
Entity type:Individual
Prefix:
First Name:GLYNIS
Middle Name:DYNEL
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 W 20TH ST APT 7
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-5359
Mailing Address - Country:US
Mailing Address - Phone:562-221-1852
Mailing Address - Fax:
Practice Address - Street 1:779 W 20TH ST APT 7
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-5359
Practice Address - Country:US
Practice Address - Phone:562-221-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice