Wallace Ray Blackwelder, D.D.S.
Individual provider Active NPI Dentist · Rowland Heights, CA
NPI 1801915939 · NPPES record last updated Jun 13, 2012
Key facts
- NPI
- 1801915939
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 031897 (CA)
- Practice address
- 19728 Colima Rd
Rowland Heights, CA 91748-3210 - Phone
- (909) 594-1758
- Fax
- (909) 594-4158
- NPI assigned
- Mar 28, 2007
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160713002460 | CA | Order and Referring Only - Dentist |
6800188798 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 031897 | CA | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| W.R. Blackwelder D.D.S. , Inc. | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 031897 | CA | Yes |
Addresses
Primary practice location
19728 Colima Rd
Rowland Heights, CA 91748-3210
Mailing address
19728 Colima Rd
Rowland Heights, CA 91748-3210
Phone (909) 594-1758
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All providers in Rowland Heights, CA · Dentist in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 13, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.