Nicholas James Wallace, DMD

Primary specialty

DentistTaxonomy code 122300000X

License

DN25997 Issued in FL

Practice address

7885 Normandy Blvd
Jacksonville, FL 32221-6640

Phone

(904) 441-5908

NPI assigned

Jun 26, 2021

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

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1624665600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1624665600000",
    "number": "1427628130",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4000 SAINT JOHNS AVE APT 5415",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322059485",
            "telephone_number": "239-398-6632"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7885 NORMANDY BLVD",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322216640",
            "telephone_number": "904-441-5908"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "NICHOLAS",
        "middle_name": "JAMES",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-06-26",
        "last_updated": "2021-06-26",
        "certification_date": "2021-06-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "FL",
            "license": "DN25997",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lisa Wallace
• Lisa Lynn Wallace, RN
• Marquita Wallace, PHARMD, RPH
• Michael Wallace, MD
• Moira Petirs Wallace, M.D.
• Patricia J Wallace, ARNP-BC
• Phillip Tyler Wallace, APRN
• Ricky Wallace
• Shanthalitta Seals Wallace, LMHC
• Taylor K Wallace, CNA

• Dentist in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Dentist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 26, 2021; 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.