Organization
C M WALLACE DDS PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CHARLES MACON WALLACE III DDS (OWNER PRESIDENT)
(239) 643-4746
Entity
Organization
Contact information
Practice address
8951 BONITA BEACH RD, BONITA SPRINGS, FL 34135-4201
(239) 992-8555
(239) 992-8644
Mailing address
8951 BONITA BEACH RD, BONITA SPRINGS, FL 34135-4201
(239) 992-8555
(239) 992-8644
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DN14024
FL
Other
Enumeration date
01/08/2007
Last updated
09/29/2010
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