Provider Demographics
NPI:1780712109
Name:WALKER, WALLACE LEE JR (DDS)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:LEE
Last Name:WALKER
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17524 DORSET AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4215
Mailing Address - Country:US
Mailing Address - Phone:248-470-0822
Mailing Address - Fax:
Practice Address - Street 1:2685 JOLLY RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3553
Practice Address - Country:US
Practice Address - Phone:517-993-5924
Practice Address - Fax:517-993-5923
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI128811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice