Individual
MRS. ANDREA L WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
D.M.D.
Contact information
Practice address
2003 S PLAZA RD, EMMETT, ID 83617-9180
(208) 365-3534
(208) 365-6231
Mailing address
2003 S PLAZA RD, EMMETT, ID 83617-9180
(208) 365-3534
(208) 365-6231
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D-3656
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8071026
—
ID
Enumeration date
08/20/2006
Last updated
07/09/2007
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