Provider Demographics
NPI:1316960131
Name:WALLACE, KEVIN BRUCE (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRUCE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S.E. 24 TERRACE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-867-9890
Mailing Address - Fax:352-622-7616
Practice Address - Street 1:949 N 14TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3838
Practice Address - Country:US
Practice Address - Phone:352-816-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15774122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist