Provider Demographics
NPI:1316930233
Name:WALLACE, JENNIFER KRISTINE (DMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:KRISTINE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 DISTANT ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1558
Mailing Address - Country:US
Mailing Address - Phone:843-986-1071
Mailing Address - Fax:
Practice Address - Street 1:BEAUFORT NAVAL HOSPITAL
Practice Address - Street 2:1 PICKNEY AVE
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-228-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice