Active NPI
John Henry Wallace, DDS
- Dentist
- Newark, OH
National Provider Identifier
1144333261
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 16606
- Practice address
- 583 Moull St
Newark, OH 43055-2909 - Phone
- (740) 366-1988
- Fax
- (740) 364-0774
- NPI assigned
- Aug 15, 2006
- Sex
- Male
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Dentist | 122300000X | 16606 | OH | Primary |
Addresses
Primary practice location
583 Moull St
Newark, OH 43055-2909
Mailing address
583 Moull St
Newark, OH 43055-2909
Phone (740) 366-1988
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0434800 | Medicaid | OH |
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)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 16606 | OH | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155600000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1144333261",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "583 MOULL ST",
"city": "NEWARK",
"state": "OH",
"postal_code": "430552909",
"telephone_number": "740-366-1988",
"fax_number": "740-364-0774"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "583 MOULL ST",
"city": "NEWARK",
"state": "OH",
"postal_code": "430552909",
"telephone_number": "740-366-1988",
"fax_number": "740-364-0774"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JOHN",
"middle_name": "HENRY",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-08-15",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "OH",
"license": "16606",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0434800",
"state": "OH"
}
],
"endpoints": [],
"other_names": []
}Other providers in Newark, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.