Stephen S Wallace, DDS

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

4383 Issued in CT

Practice address

140 Grandview Ave
Suite 102
Waterbury, CT 06708-2505

Phone

(203) 753-1112

Fax

(203) 573-0773

NPI assigned

Jun 16, 2011

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

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.

Enrollment records 1

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 and National Provider Directory roles.

• Stephen Wallace DDS PC

  • Periodontics
  • Waterbury, CT
  • NPI 1629121561
  NPD (past)

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

{
    "created_epoch": "1308182400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1332979200000",
    "number": "1679868822",
    "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": "067082505",
            "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": "067082505",
            "telephone_number": "203-753-1112",
            "fax_number": "203-573-0773"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "STEPHEN",
        "middle_name": "S",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2011-06-16",
        "last_updated": "2012-03-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_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": []
}

• Walgreen Eastern Co, Inc
• Ashley W Walker, BS
• Dana Walker
• Danielle Walker, APRN
• Tia Walker
• Yesenia Wallace
• Denise R Walsh
• Erin Walsh, MS,PT
• Heather Walsh, MD
• John James Walsh, MD-PHD

• Periodontics in Waterbury, CT
• Providers in Waterbury, CT by specialty
• Periodontics in Connecticut

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2012; 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.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.