Provider Demographics
NPI:1144498437
Name:D & A WALLACE, INC.
Entity type:Organization
Organization Name:D & A WALLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LAYNE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-365-3534
Mailing Address - Street 1:2003 E QUAIL RUN RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-5059
Mailing Address - Country:US
Mailing Address - Phone:208-365-3534
Mailing Address - Fax:208-365-6231
Practice Address - Street 1:2003 E QUAIL RUN RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5059
Practice Address - Country:US
Practice Address - Phone:208-365-3534
Practice Address - Fax:208-365-6231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3656122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8071026Medicaid