Provider Demographics
NPI:1811148638
Name:ERIC H. WALLACE D.D.S P.A.
Entity type:Organization
Organization Name:ERIC H. WALLACE D.D.S P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-391-0020
Mailing Address - Street 1:28 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-6016
Mailing Address - Country:US
Mailing Address - Phone:561-391-0020
Mailing Address - Fax:561-391-8863
Practice Address - Street 1:28 SE 6TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-6016
Practice Address - Country:US
Practice Address - Phone:561-391-0020
Practice Address - Fax:561-391-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty