Provider Demographics
NPI:1841305646
Name:WALLACE, DARREN K (DMD)
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:K
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:2003 E QUAIL RUN RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5059
Practice Address - Country:US
Practice Address - Phone:208-365-3534
Practice Address - Fax:208-365-6231
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-36411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice