McKenzie Wallace, STUDENT

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D14879 Issued in MN

Practice address

1026 7TH St W
Saint Paul, MN 55102-3828

Phone

(651) 758-9500

NPI assigned

Mar 29, 2023

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.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

Locations

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.

• United Family Practice Health Center

  • Family Medicine Physician
  • Saint Paul, MN
  • NPI 1467339622
  NPD
• United Family Practice Health Center

  • Family Medicine Physician
  • Saint Paul, MN
  • NPI 1851300149
  NPD
• Northwest Michigan Health Services, Inc.

  • Federally Qualified Health Center (FQHC)
  • Manistee, MI
  • NPI 1326589961
  NPD (past)

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

{
    "created_epoch": "1680048000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1684972800000",
    "number": "1194429597",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1026 7TH ST W",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551023828",
            "telephone_number": "651-758-9500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1026 7TH ST W",
            "city": "SAINT PAUL",
            "state": "MN",
            "postal_code": "551023828",
            "telephone_number": "651-758-9500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "MCKENZIE",
        "credential": "STUDENT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2023-03-29",
        "last_updated": "2023-05-25",
        "certification_date": "2023-05-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D14879",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Samantha Walker, LADC-S
• Walking Into Your Purpose Wellness Center LLC
• Lisa Marie Walkley
• Kevin S. Wall
• Mark C Wallace, DDS
• Shannon Marie Wallack, CRNA
• Margaret A Wallenfriedman, MD
• Mara Waller
• Sarah Waller, MSW, LICSW
• Steven Waller, MD

• 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 May 25, 2023; 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.

Verify at the official NPI Registry.