Active NPI
Martha Cochran Wallace, D.M.D.
- General Practice Dentistry
- Birmingham, AL
National Provider Identifier
1639172158
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 3030
- Practice address
- 1400 6TH Ave S
Birmingham, AL 35233-1502 - Phone
- (205) 930-1015
- Fax
- (205) 930-1448
- NPI assigned
- May 30, 2005
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 3030 | AL | Primary |
Addresses
Primary practice location
1400 6TH Ave S
Birmingham, AL 35233-1502
Mailing address
1400 6TH Ave S
Birmingham, AL 35233-1502
Phone (205) 930-1015
Other identifiers 9
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 103678 | Medicaid | AL | |
| 103676 | Medicaid | AL | |
| 1639172158 | Medicaid | AL | |
| 103546 | Medicaid | AL | |
| 510-40457 | Other | AL | BLUE CROSS BLUE SHIELD |
| 510-40458 | Other | AL | BLUE CROSS BLUE SHIELD |
| 510-40459 | Other | AL | BLUE CROSS BLUE SHIELD |
| 103578 | Medicaid | AL | |
| 510-40460 | Other | AL | BLUE CROSS BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3030 | AL | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1117411200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1294185600000",
"number": "1639172158",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1400 6TH AVE S",
"city": "BIRMINGHAM",
"state": "AL",
"postal_code": "352331502",
"telephone_number": "205-930-1015",
"fax_number": "205-930-1448"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1400 6TH AVE S",
"city": "BIRMINGHAM",
"state": "AL",
"postal_code": "352331502",
"telephone_number": "205-930-1015",
"fax_number": "205-930-1448"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "MARTHA",
"middle_name": "COCHRAN",
"name_prefix": "Dr.",
"credential": "D.M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-05-30",
"last_updated": "2011-01-05",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "AL",
"license": "3030",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "103678",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "103676",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1639172158",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "103546",
"state": "AL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "510-40457",
"state": "AL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "510-40458",
"state": "AL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "510-40459",
"state": "AL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "103578",
"state": "AL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "510-40460",
"state": "AL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Birmingham, AL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.