Provider Demographics
NPI:1952853103
Name:WALLACE COLVIN PC
Entity Type:Organization
Organization Name:WALLACE COLVIN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:S
Authorized Official - Last Name:COLVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-783-7000
Mailing Address - Street 1:69 SOUTHBOUND GRATIOT AVE LOWR
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-7600
Mailing Address - Country:US
Mailing Address - Phone:586-783-7000
Mailing Address - Fax:586-783-7003
Practice Address - Street 1:69 SOUTHBOUND GRATIOT AVE LOWR
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-7600
Practice Address - Country:US
Practice Address - Phone:586-783-7000
Practice Address - Fax:586-783-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental