Individual
R JEFFREY WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
11135 CHAPMAN HWY, SEYMOUR, TN 37865-4857
(865) 577-1963
(865) 577-1014
Mailing address
11135 CHAPMAN HWY, SEYMOUR, TN 37865-4857
(865) 577-1963
(865) 577-1014
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D54694
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0063801
BCBS
TN
Enumeration date
08/30/2006
Last updated
10/10/2016
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