Provider Demographics
NPI:1366808362
Name:JAMES C. WALLACE DDS
Entity type:Organization
Organization Name:JAMES C. WALLACE DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-273-4814
Mailing Address - Street 1:122 BANK ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6520
Mailing Address - Country:US
Mailing Address - Phone:530-273-4814
Mailing Address - Fax:
Practice Address - Street 1:122 BANK ST
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-6520
Practice Address - Country:US
Practice Address - Phone:530-273-4814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32514305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization