Provider Demographics
NPI:1124195359
Name:WALLACE, DEBORAH S (DDS)
Entity type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:S
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 HIGHWAY 79
Mailing Address - Street 2:P. O. BOX 435
Mailing Address - City:DOVER
Mailing Address - State:TN
Mailing Address - Zip Code:37058-6941
Mailing Address - Country:US
Mailing Address - Phone:931-232-8287
Mailing Address - Fax:931-232-2310
Practice Address - Street 1:445 HIGHWAY 79
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:TN
Practice Address - Zip Code:37058-6941
Practice Address - Country:US
Practice Address - Phone:931-232-8287
Practice Address - Fax:931-232-2310
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS38231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice