Organization
KEVIN D WALLACE DMD, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEVIN D WALLACE D.M.D.,P.C. (DENTIST)
(417) 881-1123
Entity
Organization
Contact information
Practice address
1200 E WOODHURST DR, SUITE 200-A, SPRINGFIELD, MO 65804-4257
(417) 881-1123
(417) 883-0812
Mailing address
1200 E WOODHURST DR, SUITE 200-A, SPRINGFIELD, MO 65804-4257
(417) 881-1123
(417) 883-0812
Taxonomy
Speciality
Code
Description
License number
State
1223P0700X
Prosthodontics
Primary
014935
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
WA405263807
—
MO
Enumeration date
05/09/2007
Last updated
08/21/2008
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