C M Wallace DDS PA

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DN14024 Issued in FL

Legal business name

C M WALLACE DDS PA

Practice address

8951 Bonita Beach Rd
Bonita Springs, FL 34135-4201

Phone

(239) 992-8555

Fax

(239) 992-8644

NPI assigned

Jan 8, 2007

Organization subpart

No

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

Authorized official

Name

Dr. Charles Macon Wallace III, DDS

Title

Owner President

Phone

(239) 643-4746

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1168214400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1285718400000",
    "number": "1578612925",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8951 BONITA BEACH RD",
            "city": "BONITA SPRINGS",
            "state": "FL",
            "postal_code": "341354201",
            "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",
            "city": "BONITA SPRINGS",
            "state": "FL",
            "postal_code": "341354201",
            "telephone_number": "239-992-8555",
            "fax_number": "239-992-8644"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "C M WALLACE DDS PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-08",
        "last_updated": "2010-09-29",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "MACON",
        "authorized_official_title_or_position": "OWNER PRESIDENT",
        "authorized_official_telephone_number": "239-643-4746",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "III",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "FL",
            "license": "DN14024",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Erin Lynn Brouillard, PA-C
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• Kyle Aaron Burton, M.D.
• Maria Ximena Bustamante, PA-C
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• 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 Sep 29, 2010; 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.