# DR. JOHN KLINE WALLACE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1316038839
- **Gender:** Man
- **Credential:** DDS

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 0401005254 | VA | Yes |

## Other

- **Enumeration date:** 09/28/2006
- **Last updated:** 07/08/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 080223 | ANTHEM BCBS | — |
| 01 | — | 0821731 | AETNA | — |
| 05 | — | 7821565 | — | VA |
| 01 | — | 9130 | DORAL DENTAL | — |