Active NPI
Kevin Bruce Wallace, D.M.D.
- Dentist
- Leesburg, FL
National Provider Identifier
1316960131
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- DN15774
- Practice address
- 949 N 14TH St
Leesburg, FL 34748-3838 - Phone
- (352) 816-0855
- NPI assigned
- Jul 25, 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 | DN15774 | FL | Primary |
Addresses
Primary practice location
949 N 14TH St
Leesburg, FL 34748-3838
Mailing address
1107 S.E. 24 Terrace
Ocala, FL 34471
Phone (352) 867-9890
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)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DN15774 | FL | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153785600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1320192000000",
"number": "1316960131",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1107 S.E. 24 TERRACE",
"city": "OCALA",
"state": "FL",
"postal_code": "34471",
"telephone_number": "352-867-9890",
"fax_number": "352-622-7616"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "949 N 14TH ST",
"city": "LEESBURG",
"state": "FL",
"postal_code": "347483838",
"telephone_number": "352-816-0855"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "KEVIN",
"middle_name": "BRUCE",
"name_prefix": "Dr.",
"credential": "D.M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-07-25",
"last_updated": "2011-11-02",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "FL",
"license": "DN15774",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Leesburg, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.