Active NPI
Heath R Wallace
- Dentist
- Weston, OH
National Provider Identifier
1811010069
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 30-022208
- Practice address
- 13160 Main Street
Weston, OH 43569 - Phone
- (419) 669-2839
- NPI assigned
- Apr 10, 2007
- Sex
- Male
- Sole proprietor
- Yes
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 |
|---|---|---|---|---|
| Dentist | 122300000X | 30-022208 | OH | Primary |
Addresses
Primary practice location
13160 Main Street
Weston, OH 43569
Mailing address
13160 Main Street
Weston, OH 43569
Phone (419) 669-2839
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OH
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150618001403 | OH | Order and Referring Only - Dentist | 1658682521 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30-022208 | OH | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176163200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1811010069",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "13160 MAIN STREET",
"city": "WESTON",
"state": "OH",
"postal_code": "43569",
"telephone_number": "419-669-2839"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "13160 MAIN STREET",
"city": "WESTON",
"state": "OH",
"postal_code": "43569",
"telephone_number": "419-669-2839"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "HEATH",
"middle_name": "R",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-04-10",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "OH",
"license": "30-022208",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Weston, OH
Sources for this page
- 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.