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Individual
DR. JOHN KLINE WALLACE
Active
Individual
DR. JOHN KLINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
0401005254
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080223
ANTHEM BCBS
—
01
—
0821731
AETNA
—
05
—
7821565
—
VA
01
—
9130
DORAL DENTAL
—
Enumeration date
09/28/2006
Last updated
07/08/2007
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