Mark C Wallace, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D12888 Issued in MN

Practice address

50 County Road B E
Saint Paul, MN 55117-1927

Phone

(651) 488-2541

Fax

(651) 488-8944

NPI assigned

May 1, 2007

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

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.

Opted out of Medicare

Yes, effective Jan 2, 2017 through Jan 2, 2027

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

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

• Point Family Dentistry

  • General Practice Dentistry
  • Bloomington, MN
  • NPI 1942668702
  NPD (past) Authorized official

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

{
    "created_epoch": "1177977600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1340582400000",
    "number": "1104047190",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6642 PICHA PL",
            "city": "EDEN PRAIRIE",
            "state": "MN",
            "postal_code": "553462508",
            "telephone_number": "952-500-9805"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "50 COUNTY ROAD B E",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551171927",
            "telephone_number": "651-488-2541",
            "fax_number": "651-488-8944"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MARK",
        "middle_name": "C",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-05-01",
        "last_updated": "2012-06-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "5919",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D12888",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Robyn Rose Walker, MA, LPCC, LADC
• Samantha Walker, LADC-S
• Walking Into Your Purpose Wellness Center LLC
• Lisa Marie Walkley
• Kevin S. Wall
• McKenzie Wallace, STUDENT
• Shannon Marie Wallack, CRNA
• Margaret A Wallenfriedman, MD
• Mara Waller
• Sarah Waller, MSW, LICSW

• General Practice Dentistry in Saint Paul, MN
• Providers in Saint Paul, MN by specialty
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2012; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.