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Individual
DR. MARK C WALLACE
Active
Individual
DR. MARK C WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
5919
WA
1223G0001X
General Practice Dentistry
Primary
D12888
MN
Other
Enumeration date
05/01/2007
Last updated
06/25/2012
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