Individual
DR. GEORGE MARVIN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D. D. S.
Contact information
Practice address
710 N ELM ST, HIGH POINT, NC 27262-3918
(336) 882-4181
(336) 464-2166
Mailing address
710 N ELM ST, HIGH POINT, NC 27262-3918
(336) 882-4181
(336) 464-2166
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
3016
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1063559748
NPI #
NC
01
—
3016
STATE LICENSE #
NC
01
—
56-0814633
TAX ID #
NC
05
—
8998840
—
NC
Enumeration date
01/31/2007
Last updated
04/25/2017
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