Provider Demographics
NPI:1841962529
Name:BENJAMIN C. WALLACE DDS, PLLC
Entity type:Organization
Organization Name:BENJAMIN C. WALLACE DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-724-7824
Mailing Address - Street 1:1796 GRAND RIDGE CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7035
Mailing Address - Country:US
Mailing Address - Phone:616-724-7824
Mailing Address - Fax:
Practice Address - Street 1:1330 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2190
Practice Address - Country:US
Practice Address - Phone:616-754-7414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental