# DR. DEDRA DESIREE DAVIS-WALLACE

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

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

## Provider details

- **NPI number:** 1518057934
- **Gender:** F
- **Credential:** DDS

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | 1001197-15 | WI | Yes |
| 1223P0221X | Pediatric Dentistry | 24891 | TX | — |
| 1223P0221X | Pediatric Dentistry | DN012272 | GA | — |

## Other

- **Enumeration date:** 10/14/2006
- **Last updated:** 07/12/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1518057934 | — | WI |