Phillip W Wallace DDS Inc

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

30.016266 Issued in OH

Legal business name

PHILLIP W WALLACE DDS INC

Practice address

36001 Euclid Ave
Suite a-15
Willoughby, OH 44094-4643

Phone

(440) 946-5485

Fax

(440) 946-5810

NPI assigned

Dec 8, 2015

Last updated

Dec 8, 2015By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Phillip W Wallace, DDSNPI 1083759930

Title

Owner

Phone

(440) 946-5484

Specialties & licenses 1

Addresses

Locations

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.

• Phillip Wendell Wallace, D.D.S.

  • General Practice Dentistry
  • Willoughby, OH
  • NPI 1083759930
  NPD (past) Authorized official

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

{
    "created_epoch": "1449532800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1449532800000",
    "number": "1699140202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "36001 EUCLID AVE",
            "address_2": "SUITE A-15",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440944643",
            "telephone_number": "440-946-5485",
            "fax_number": "440-946-5810"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "36001 EUCLID AVE",
            "address_2": "SUITE A-15",
            "city": "WILLOUGHBY",
            "state": "OH",
            "postal_code": "440944643",
            "telephone_number": "440-946-5485",
            "fax_number": "440-946-5810"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHILLIP W WALLACE DDS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-12-08",
        "last_updated": "2015-12-08",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "PHILLIP",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "440-946-5484",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "OH",
            "license": "30.016266",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Michele Elizabeth Petruccelli
• Kristin Petruziello, CNP
• Maria C Petty, NURSE PRACTITIONER
• Jill K. Peysha
• Lydia Pfeifle, LMT
• Amanda Ann Phillips, PT
• Phoenix Counseling and Wellness, LLC
• Tracey L Picard
• Ante Pilekic
• Tomislav Pilekic

• General Practice Dentistry in Willoughby, OH
• Providers in Willoughby, OH by specialty
• General Practice Dentistry in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 8, 2015; 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.