R Jeffrey Wallace, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

D54694 Issued in TN

Practice address

11135 Chapman Hwy
Seymour, TN 37865-4857

Phone

(865) 577-1963

Fax

(865) 577-1014

NPI assigned

Aug 30, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in TN

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

State licenses

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

{
    "created_epoch": "1156896000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1476057600000",
    "number": "1285744151",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11135 CHAPMAN HWY",
            "city": "SEYMOUR",
            "state": "TN",
            "postal_code": "378654857",
            "telephone_number": "865-577-1963",
            "fax_number": "865-577-1014"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11135 CHAPMAN HWY",
            "city": "SEYMOUR",
            "state": "TN",
            "postal_code": "378654857",
            "telephone_number": "865-577-1963",
            "fax_number": "865-577-1014"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "R",
        "middle_name": "JEFFREY",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-30",
        "last_updated": "2016-10-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TN",
            "license": "D54694",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "0063801",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2016; 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.