Wallace Spurgeon Colvin III, D.D.S.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2901016347 Issued in MI

Practice address

69 Southbound Gratiot Ave
Mount Clemens, MI 48043-5545

Phone

(586) 783-7000

Fax

(586) 783-7003

NPI assigned

Dec 5, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MI

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

Practice roles

Interoperability endpoints

• Direct secure messaging: wallace.colvin.1@17661.direct.athenahealth.com

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.

• United Health Centers of the San Joaquin Valley

  • Federally Qualified Health Center (FQHC)
  • Huron, CA
  • NPI 1134101686
  NPD (past)

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

{
    "created_epoch": "1165276800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1730247222",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "69 SOUTHBOUND GRATIOT AVE",
            "city": "MOUNT CLEMENS",
            "state": "MI",
            "postal_code": "480435545",
            "telephone_number": "586-783-7000",
            "fax_number": "586-783-7003"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "69 SOUTHBOUND GRATIOT AVE",
            "city": "MOUNT CLEMENS",
            "state": "MI",
            "postal_code": "480435545",
            "telephone_number": "586-783-7000",
            "fax_number": "586-783-7003"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "COLVIN",
        "first_name": "WALLACE",
        "middle_name": "SPURGEON",
        "name_prefix": "Dr.",
        "name_suffix": "III",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-05",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901016347",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4263930",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Clinton Counseling Center
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• Lauren Therese Cody, RD, IBCLC
• James Arthur Coleman
• Shelia Renee Collins, LLMSW
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• Community Cancer Care Specialists
• Community Cancer Care Specialists
• Comprehensive Youth Services Inc
• Maurica Cook

• General Practice Dentistry in Mount Clemens, MI
• Providers in Mount Clemens, MI by specialty
• General Practice Dentistry in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; 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.