Kevin R Wallace, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

019022339 Issued in IL

Practice address

150 E Huron St
Ste 1103
Chicago, IL 60611

Phone

(312) 676-9893

Fax

(815) 744-7059

NPI assigned

Sep 1, 2006

Last updated

Jan 19, 2021By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 8

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Oral Surgery

Education

Other, 1990

Medicare assignment

May accept Medicare assignment

Telehealth

Offers telehealth services

Group practices

Dental Sleep Center Richard a Craig DDS LTDGroup PAC ID 8820287121, 4 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Northwestern Memorial Hospital Hospital, Chicago, IL, CCN 140281
• Advocate Lutheran General Hospital Hospital, Park Ridge, IL, CCN 140223
• Northwestern Lake Forest Hospital Hospital, Lake Forest, IL, CCN 140130
• Advocate Good Shepherd Hospital Hospital, Barrington, IL, CCN 140291
• Advocate Illinois Masonic Medical Center Hospital, Chicago, IL, CCN 140182

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://fhir4.healow.com/fhir/r4/FGDEAA/Endpoint/FGDEAA

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Dental Sleep Center Richard a Craig DDS LTD

  dba Midwest Dental Sleep Center

  • Dental Clinic/Center
  • Homer Glen, IL
  • NPI 1053431981

  General Practice

  Medicare reassignment Care Compare group NPD
• Dental Sleep Center Richard a Craig DDS LTD

  dba Midwest Dental Sleep Center

  • Dental Clinic/Center
  • Lombard, IL
  • NPI 1306177241

  General Practice

  NPD
• Dental Sleep Center Richard a Craig DDS LTD

  dba Midwest Dental Sleep Center

  • Dental Clinic/Center
  • Skokie, IL
  • NPI 1760882005

  General Practice

  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Advocate Health and Hospitals Corporation

  dba Advocate Lutheran General Hospital

  • General Acute Care Hospital
  • Park Ridge, IL
  • NPI 1164539730
  Care Compare affiliation
• Advocate Health and Hospitals Corporation

  dba Advocate Good Shepherd Hospital

  • General Acute Care Hospital
  • Barrington, IL
  • NPI 1447368071
  Care Compare affiliation
• Advocate North Side Health Network

  dba Advocate Illinois Masonic Medical Center

  • General Acute Care Hospital
  • Chicago, IL
  • NPI 1912014564
  Care Compare affiliation
• Northwestern Lake Forest Hospital

  dba Northwestern Medicine Lake Forest Hospital

  • General Acute Care Hospital
  • Lake Forest, IL
  • NPI 1124025176
  Care Compare affiliation
• Northwestern Memorial Hospital

  • General Acute Care Hospital
  • Chicago, IL
  • NPI 1497859649
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1157068800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1611014400000",
    "number": "1053423285",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14831 W 159TH ST STE 1",
            "city": "LOCKPORT",
            "state": "IL",
            "postal_code": "604919008",
            "telephone_number": "630-324-5369",
            "fax_number": "815-744-7059"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "150 E HURON ST",
            "address_2": "STE 1103",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "60611",
            "telephone_number": "312-676-9893",
            "fax_number": "815-744-7059"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KEVIN",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-01",
        "last_updated": "2021-01-19",
        "certification_date": "2021-01-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019022339",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019-022339",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019022339",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRACTICE LOCATION TYPE II NPI",
            "identifier": "1508198474",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP TYPE II NPI",
            "identifier": "1063649770",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRACTICE LOCATION TYPE II NPI",
            "identifier": "1760882005",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRACTICE LOCATION TYPE II NPI",
            "identifier": "1205145554",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DENTAL-IL",
            "identifier": "019-022339",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRACTICE LOCATION TYPE II NPI",
            "identifier": "1306177241",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP TYPE II NPI",
            "identifier": "1053431981",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRACTICE LOCATION TYPE II NPI",
            "identifier": "1295165439",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Hyacinth Wallace, P.T, DPT
• James A Wallace
• Jessica Gensler Wallace, DNP
• Kathleen Wallace
• Keith V. Wallace, L.C.S.W.
• Lawanda Wallace
• Maria L Wallace
• Megan Ann Wallace, M.A., CCC-SLP/LD
• Nicole Wallace
• Robert J Wallace, LAC, LMT

• General Practice Dentistry in Chicago, IL
• Providers in Chicago, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 19, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.