Individual
MCKENZIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
STUDENT
Contact information
Practice address
1026 7TH ST W, SAINT PAUL, MN 55102-3828
(651) 758-9500
Mailing address
1026 7TH ST W, SAINT PAUL, MN 55102-3828
(651) 758-9500
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D14879
MN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/29/2023
Last updated
05/25/2023
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