Provider Demographics
NPI:1811978349
Name:WALLACE, JOHN DAVID (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
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Mailing Address - Street 1:8315 WALNUT HILL LN STE 120
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4218
Mailing Address - Country:US
Mailing Address - Phone:214-363-9946
Mailing Address - Fax:214-389-1953
Practice Address - Street 1:8315 WALNUT HILL LN STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4218
Practice Address - Country:US
Practice Address - Phone:214-363-9946
Practice Address - Fax:214-389-1953
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX198621223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1750242-02Medicaid
TX8F1255Medicare ID - Type Unspecified