Provider Demographics
NPI:1427628130
Name:WALLACE, NICHOLAS JAMES (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAMES
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 1:4000 SAINT JOHNS AVE APT 5415
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-9485
Mailing Address - Country:US
Mailing Address - Phone:239-398-6632
Mailing Address - Fax:
Practice Address - Street 1:7885 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-6640
Practice Address - Country:US
Practice Address - Phone:904-441-5908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25997122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist