C.M. Wallace, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DN14024 Issued in FL

Practice address

8951 Bonita Beach Rd SE Ste 206
Bonita Springs, FL 34135-4202

Phone

(239) 992-8555

Fax

(239) 992-8644

NPI assigned

Dec 6, 2013

Last updated

Dec 6, 2013By the provider in NPPES

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 names 1

• Charles Macon Wallace Professional name

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": "1386288000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1386288000000",
    "number": "1487085072",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8951 BONITA BEACH RD SE STE 206",
            "city": "BONITA SPRINGS",
            "state": "FL",
            "postal_code": "341354202",
            "telephone_number": "239-992-8555",
            "fax_number": "239-992-8644"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8951 BONITA BEACH RD SE STE 206",
            "city": "BONITA SPRINGS",
            "state": "FL",
            "postal_code": "341354202",
            "telephone_number": "239-992-8555",
            "fax_number": "239-992-8644"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "C.M.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-12-06",
        "last_updated": "2013-12-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "FL",
            "license": "DN14024",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "CHARLES",
            "last_name": "WALLACE",
            "middle_name": "MACON",
            "credential": "DDS",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Samantha S Wadas, OTR/L
• Walgreen Co (Walgreens #04165)
• Walgreen Co (Walgreens #6499)
• Walgreen Co (Walgreens #07851)
• Walgreens
• Ryan James Wallace, PT, DPT, OCS, MTC
• Caroline Anne Walters, MA CCC SLP
• Phyllis Annette Walters
• Scott Walters, DC
• Fang Wang

• General Practice Dentistry in Bonita Springs, FL
• Providers in Bonita Springs, FL by specialty
• General Practice Dentistry in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2013; 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.