Organization
STEPHEN WALLACE DDS PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENNIFER M CATHCART (OFFICE MANAGER)
(203) 753-1112
Entity
Organization
Contact information
Practice address
140 GRANDVIEW AVE, SUITE 102, WATERBURY, CT 06708
(203) 753-1112
(203) 573-0773
Mailing address
140 GRANDVIEW AVE, SUITE 102, WATERBURY, CT 06708
(203) 753-1112
(203) 573-0773
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
044912-1
NY
1223P0300X
Periodontics
Primary
4383
CT
1223P0300X
Periodontics
DN11169
MA
Other
Enumeration date
01/22/2007
Last updated
03/22/2012
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