# DR. GEORGE MARVIN WALLACE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1063559748
- **Gender:** Man
- **Credential:** D. D. S.

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 3016 | NC | Yes |

## Other

- **Enumeration date:** 01/31/2007
- **Last updated:** 04/25/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1063559748 | NPI \# | NC |
| 01 | — | 3016 | STATE LICENSE \# | NC |
| 01 | — | 56-0814633 | TAX ID \# | NC |
| 05 | — | 8998840 | — | NC |