Provider Demographics
NPI:1194217315
Name:MASSA WALLACE, NATALIE TAYLOR (DDS)
Entity type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:TAYLOR
Last Name:MASSA WALLACE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:TAYLOR
Other - Last Name:MASSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6834 ROLFE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-7596
Mailing Address - Country:US
Mailing Address - Phone:614-674-8744
Mailing Address - Fax:
Practice Address - Street 1:1012 STATE ROUTE 521 STE 202
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015
Practice Address - Country:US
Practice Address - Phone:740-417-9565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0254361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice