Active NPI
Marshall Lynn Wallace, DMD
- Periodontics
- Sumter, SC
National Provider Identifier
1124092697
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 2839/363
- Practice address
- 3 Professional CT
Sumter, SC 29150-1927 - Phone
- (803) 469-9461
- Fax
- (803) 469-9023
- NPI assigned
- Feb 14, 2006
- 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 |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 2839/363 | SC | Primary |
Addresses
Primary practice location
3 Professional CT
Sumter, SC 29150-1927
Mailing address
3 Professional CT
Sumter, SC 29150-1927
Phone (803) 469-9461
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ZA9760 | Medicaid | SC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20140519000720 | SC | Order and Referring Only - Oral Surgery | 1850514977 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2839/363 | SC | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1139875200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1124092697",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3 PROFESSIONAL CT",
"city": "SUMTER",
"state": "SC",
"postal_code": "291501927",
"telephone_number": "803-469-9461",
"fax_number": "803-469-9023"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3 PROFESSIONAL CT",
"city": "SUMTER",
"state": "SC",
"postal_code": "291501927",
"telephone_number": "803-469-9461",
"fax_number": "803-469-9023"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "MARSHALL",
"middle_name": "LYNN",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-14",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "SC",
"license": "2839/363",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "ZA9760",
"state": "SC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Sumter, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.