Patrick L Wallace, D.D.S.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

4988 Issued in OK

Practice address

1119 Walnut Dr
Suite 2
Ardmore, OK 73401-2360

Phone

(580) 226-1727

Fax

(580) 226-9413

NPI assigned

Nov 3, 2005

Last updated

Jan 13, 2014By 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 identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

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.

Opted out of Medicare

Yes, effective Jul 1, 2014 through Jul 1, 2028

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Okc-Oms Holdings PLLC

  • Oral and Maxillofacial Surgery (Dentist)
  • Oklahoma City, OK
  • NPI 1487064002
  NPD (past)
• Oms of Southern Oklahoma PLLC

  • Oral and Maxillofacial Surgery (Dentist)
  • Ardmore, OK
  • NPI 1447660063
  NPD (past)

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

{
    "created_epoch": "1130976000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1389571200000",
    "number": "1508857053",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 108816",
            "city": "OKLAHOMA CITY",
            "state": "OK",
            "postal_code": "731018816",
            "telephone_number": "405-848-7974",
            "fax_number": "405-848-0033"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1119 WALNUT DR",
            "address_2": "SUITE 2",
            "city": "ARDMORE",
            "state": "OK",
            "postal_code": "734012360",
            "telephone_number": "580-226-1727",
            "fax_number": "580-226-9413"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "PATRICK",
        "middle_name": "L",
        "name_prefix": "Dr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-11-03",
        "last_updated": "2014-01-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "OK",
            "license": "4988",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100119640A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Sallie J Walker, MS, RN, ARNP
• Stephanie Kaytlynn Walker
• Sawyer Wall
• Ashley Wallace
• Jamie Wallace
• Shelby Wallace
• Rachel Wallis
• Walls Family Chiropractic Inc
• Buel M Walls, DC
• Walnut Ranch Dental Spa GPS, PLLC

• Oral and Maxillofacial Surgery (Dentist) in Ardmore, OK
• Providers in Ardmore, OK by specialty
• Oral and Maxillofacial Surgery (Dentist) in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 13, 2014; 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; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.