Provider Demographics
NPI:1306066345
Name:WALLACE, TERRY ANTHONY (DDS)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:ANTHONY
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27846-9117
Mailing Address - Country:US
Mailing Address - Phone:252-792-1032
Mailing Address - Fax:252-792-2304
Practice Address - Street 1:2165 MAIN ST
Practice Address - Street 2:
Practice Address - City:JAMESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27846-9117
Practice Address - Country:US
Practice Address - Phone:252-792-1032
Practice Address - Fax:252-792-2304
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC44131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice