Provider Demographics
NPI:1699741777
Name:WALLACE, DENNIS JAYE (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:JAYE
Last Name:WALLACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:J
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:662 EAST VISALIA ROAD
Mailing Address - Street 2:PO BOX 475
Mailing Address - City:FARMERSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93223-0475
Mailing Address - Country:US
Mailing Address - Phone:559-747-3461
Mailing Address - Fax:559-594-4059
Practice Address - Street 1:662 EAST VISALIA ROAD
Practice Address - Street 2:
Practice Address - City:FARMERSVILLE
Practice Address - State:CA
Practice Address - Zip Code:93223
Practice Address - Country:US
Practice Address - Phone:559-747-3461
Practice Address - Fax:559-594-4059
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5964 TPA152W00000X
MT406OPT TPA152W00000X
WAOD00001112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2868614OtherMEDICAL PASSWORD
SD0059640OtherBLUE SHIELD
CASD0059641Medicaid
SD0059641Medicare ID - Type Unspecified
SD0059640OtherBLUE SHIELD