Mark Charles Wallace, DDS, PC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

MARK CHARLES WALLACE, DDS, PC

Practice address

3909 Silver Lake Rd NE
Minneapolis, MN 55421-4352

Phone

(612) 789-3573

NPI assigned

Jan 8, 2014

Organization subpart

No

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

Authorized official

Name

Rebecca M Kipp

Title

Office Manager

Phone

(612) 789-3573

Specialties & licenses 1

Addresses

Other names 1

• Advanced Dental Group Doing business as

Locations

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

{
    "created_epoch": "1389139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1389139200000",
    "number": "1184046385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3909 SILVER LAKE RD NE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554214352",
            "telephone_number": "612-789-3573"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3909 SILVER LAKE RD NE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554214352",
            "telephone_number": "612-789-3573"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARK CHARLES WALLACE, DDS, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-08",
        "last_updated": "2014-01-08",
        "status": "A",
        "authorized_official_last_name": "KIPP",
        "authorized_official_first_name": "REBECCA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "612-789-3573"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Advanced Dental Group",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Andrew Raymond Marjala, PHARMD
• Susanna M Marjanovich, CNP
• Mark K Yamaguchi PC
• Kristen Mark, PHD, MPH
• Melissa C. Mark, M.D.
• Madeline Miles Marker
• Stephen Marker

• General Practice Dentistry in Minneapolis, MN
• Providers in Minneapolis, 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 Jan 8, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.