Individual
DR. JOHN KLINE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2501 PRINCESS ANNE ST, FREDERICKSBURG, VA 22401-3333
(540) 371-0004
Mailing address
2501 PRINCESS ANNE ST, FREDERICKSBURG, VA 22401-3333
(540) 371-0004
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
0401005254
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080223
ANTHEM BCBS
—
01
—
0821731
AETNA
—
05
—
7821565
—
VA
01
—
9130
DORAL DENTAL
—
Enumeration date
09/28/2006
Last updated
07/08/2007
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