NPIMap

Organization Active NPI

Stephen Wallace DDS PC

  • Periodontics
  • Waterbury, CT
National Provider Identifier
1629121561
Registry record updated Mar 22, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
License
4383 Issued in CT
Legal business name
STEPHEN WALLACE DDS PC
Practice address
140 Grandview Ave
Suite 102
Waterbury, CT 06708
Phone
(203) 753-1112
Fax
(203) 573-0773
NPI assigned
Jan 22, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 22, 2012

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

Authorized official

Name
Mrs. Jennifer M Cathcart
Title
Office Manager
Phone
(203) 753-1112

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193200000X MULTI-SPECIALTY GROUP 1223P0300X 4383 CT Primary
PeriodonticsGroup: 193200000X MULTI-SPECIALTY GROUP 1223P0300X 044912-1 NY
PeriodonticsGroup: 193200000X MULTI-SPECIALTY GROUP 1223P0300X DN11169 MA

Addresses

Primary practice location

140 Grandview Ave
Suite 102
Waterbury, CT 06708

Mailing address

140 Grandview Ave
Suite 102
Waterbury, CT 06708
Phone (203) 753-1112

National Provider Directory

National Provider Directory

Locations

140 Grandview Ave
Ste 102
Waterbury, CT 06708
Phone (203) 753-1112

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1169424000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1332374400000",
    "number": "1629121561",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "140 GRANDVIEW AVE",
            "address_2": "SUITE 102",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "06708",
            "telephone_number": "203-753-1112",
            "fax_number": "203-573-0773"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "140 GRANDVIEW AVE",
            "address_2": "SUITE 102",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "06708",
            "telephone_number": "203-753-1112",
            "fax_number": "203-573-0773"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STEPHEN WALLACE DDS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-22",
        "last_updated": "2012-03-22",
        "status": "A",
        "authorized_official_last_name": "CATHCART",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "203-753-1112",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "CT",
            "license": "4383",
            "primary": true
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "NY",
            "license": "044912-1",
            "primary": false
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "MA",
            "license": "DN11169",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Waterbury, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2012; 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.