Provider Demographics
NPI:1467333500
Name:WALLACE, DAKOTA JAMES
Entity type:Individual
Prefix:
First Name:DAKOTA
Middle Name:JAMES
Last Name:WALLACE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 POPLAR CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:KY
Mailing Address - Zip Code:42728-8460
Mailing Address - Country:US
Mailing Address - Phone:812-801-5784
Mailing Address - Fax:
Practice Address - Street 1:194 POPLAR CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-8460
Practice Address - Country:US
Practice Address - Phone:812-801-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program