Individual
DR. BRIAN WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
781 S LAKE DR, SUITE 1, PRESTONSBURG, KY 41653-1340
(606) 886-2676
(606) 886-2741
Mailing address
3900 KY ROUTE 1750, EAST POINT, KY 41216-8824
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
7008
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
60070083
—
KY
Enumeration date
01/16/2007
Last updated
07/08/2007
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