Provider Demographics
NPI:1982753844
Name:BELLAMY, WALLACE JEROME (DMD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:JEROME
Last Name:BELLAMY
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 1:8007 LAGUNA BLVD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7920
Mailing Address - Country:US
Mailing Address - Phone:916-683-3011
Mailing Address - Fax:916-683-4764
Practice Address - Street 1:8007 LAGUNA BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7920
Practice Address - Country:US
Practice Address - Phone:916-683-3011
Practice Address - Fax:916-683-4764
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA389651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice