Active NPI
Charles Wayne Wallace, DDS
- General Practice Dentistry
- Staunton, VA
National Provider Identifier
1073643862
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 0401003798
- Practice address
- 502 N Coalter St
Staunton, VA 24401-3401 - Phone
- (540) 885-3060
- NPI assigned
- Mar 7, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 0401003798 | VA | Primary |
Addresses
Primary practice location
502 N Coalter St
Staunton, VA 24401-3401
Mailing address
502 N Coalter St
Staunton, VA 24401-3401
Phone (540) 885-3060
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| B23831643 | Other | VA | DRIVER'S LICENSE |
| 0401003798 | Other | VA | DENTAL LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0401003798 | VA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173225600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1678147200000",
"number": "1073643862",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "502 N COALTER ST",
"city": "STAUNTON",
"state": "VA",
"postal_code": "244013401",
"telephone_number": "540-885-3060"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "502 N COALTER ST",
"city": "STAUNTON",
"state": "VA",
"postal_code": "244013401",
"telephone_number": "540-885-3060"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "CHARLES",
"middle_name": "WAYNE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-07",
"last_updated": "2023-03-07",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "VA",
"license": "0401003798",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DRIVER'S LICENSE",
"identifier": "B23831643",
"state": "VA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DENTAL LICENSE",
"identifier": "0401003798",
"state": "VA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Staunton, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.