Individual
DR. KEVIN R WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
150 E HURON ST, STE 1103, CHICAGO, IL 60611
(312) 676-9893
(815) 744-7059
Mailing address
14831 W 159TH ST STE 1, LOCKPORT, IL 60491-9008
(630) 324-5369
(815) 744-7059
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
019-022339
IL
122300000X
Dentist
019022339
IL
1223G0001X
General Practice Dentistry
Primary
019022339
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
019-022339
DENTAL-IL
IL
01
—
1053431981
GROUP TYPE II NPI
IL
01
—
1063649770
GROUP TYPE II NPI
IL
01
—
1205145554
PRACTICE LOCATION TYPE II NPI
IL
01
—
1295165439
PRACTICE LOCATION TYPE II NPI
IL
01
—
1306177241
PRACTICE LOCATION TYPE II NPI
IL
01
—
1508198474
PRACTICE LOCATION TYPE II NPI
IL
01
—
1760882005
PRACTICE LOCATION TYPE II NPI
IL
Enumeration date
09/01/2006
Last updated
01/19/2021
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