Provider Demographics
NPI:1427440957
Name:WALLACE, RAY LINTON III (DMD)
Entity type:Individual
Prefix:DR
First Name:RAY
Middle Name:LINTON
Last Name:WALLACE
Suffix:III
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 1:2431 MCDOWELL ST
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-0401
Mailing Address - Country:US
Mailing Address - Phone:912-695-2801
Mailing Address - Fax:
Practice Address - Street 1:2431 MCDOWELL ST
Practice Address - Street 2:APARTMENT 3
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-0401
Practice Address - Country:US
Practice Address - Phone:912-695-2801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program