Individual
DR. MICHAEL J WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1617 E DANFORTH RD, EDMOND, OK 73034-3103
(405) 340-0411
(405) 340-3217
Mailing address
1617 E DANFORTH ROAD, EDMOND, OK 73034-6622
(405) 340-0411
(405) 340-3217
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
5801
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200066490 A
—
OK
Enumeration date
01/02/2007
Last updated
01/28/2021
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