Individual
DENNIS JAYE WALLACE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
662 EAST VISALIA ROAD, FARMERSVILLE, CA 93223
(559) 747-3461
(559) 594-4059
Mailing address
662 EAST VISALIA ROAD, PO BOX 475, FARMERSVILLE, CA 93223-0475
(559) 747-3461
(559) 594-4059
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
406OPT TPA
MT
152W00000X
Optometrist
OD00001112
WA
152W00000X
Optometrist
Primary
OPT5964 TPA
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2868614
MEDICAL PASSWORD
CA
01
—
SD0059640
BLUE SHIELD
—
05
—
SD0059641
—
CA
Enumeration date
02/27/2006
Last updated
07/08/2007
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