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Individual
DR. CHARLES WAYNE WALLACE
Active
Individual
DR. CHARLES WAYNE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
0401003798
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0401003798
DENTAL LICENSE
VA
01
—
B23831643
DRIVER'S LICENSE
VA
Enumeration date
03/07/2007
Last updated
03/07/2023
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