Provider Demographics
NPI:1144341876
Name:WALLACE, NANCY SMITH (DMD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:SMITH
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BRIAR LN
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2750
Mailing Address - Country:US
Mailing Address - Phone:847-735-9468
Mailing Address - Fax:847-735-9572
Practice Address - Street 1:1709 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5133
Practice Address - Country:US
Practice Address - Phone:847-662-6080
Practice Address - Fax:847-662-6086
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice