Provider Demographics
NPI:1972750909
Name:WALLACE, KEVIN D (DMD PC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD PC
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Mailing Address - Street 1:1200 E WOODHURST DR STE A200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3745
Mailing Address - Country:US
Mailing Address - Phone:417-881-1123
Mailing Address - Fax:417-883-0812
Practice Address - Street 1:1200 E WOODHURST DR STE A200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3745
Practice Address - Country:US
Practice Address - Phone:417-881-1123
Practice Address - Fax:417-883-0812
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO0149351223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics