NPIMap

Organization Active NPI

Kevin D Wallace DMD, PC

  • Prosthodontics
  • Springfield, MO
National Provider Identifier
1841404019
Registry record updated Aug 21, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
ProsthodonticsTaxonomy code 1223P0700X
License
014935 Issued in MO
Legal business name
KEVIN D WALLACE DMD, PC
Practice address
1200 E Woodhurst Dr
Suite 200-a
Springfield, MO 65804-4257
Phone
(417) 881-1123
Fax
(417) 883-0812
NPI assigned
May 9, 2007
Last updated
Aug 21, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 21, 2008

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

Authorized official

Name
Dr. Kevin D Wallace, D.M.D.,P.C.NPI 1972750909
Title
Dentist
Phone
(417) 881-1123

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Prosthodontics 1223P0700X 014935 MO Primary

Addresses

Primary practice location

1200 E Woodhurst Dr
Suite 200-a
Springfield, MO 65804-4257

Mailing address

1200 E Woodhurst Dr
Suite 200-a
Springfield, MO 65804-4257
Phone (417) 881-1123

Other identifiers 1

IdentifierTypeStateIssuer
WA405263807MedicaidMO

National Provider Directory

National Provider Directory

Locations

1200 E Woodhurst Dr
Ste A200
Springfield, MO 65804
Phone (417) 881-1123

Practitioners & affiliated clinicians

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.

NPI Registry JSON

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

{
    "created_epoch": "1178668800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1219276800000",
    "number": "1841404019",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 E WOODHURST DR",
            "address_2": "SUITE 200-A",
            "city": "SPRINGFIELD",
            "state": "MO",
            "postal_code": "658044257",
            "telephone_number": "417-881-1123",
            "fax_number": "417-883-0812"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 E WOODHURST DR",
            "address_2": "SUITE 200-A",
            "city": "SPRINGFIELD",
            "state": "MO",
            "postal_code": "658044257",
            "telephone_number": "417-881-1123",
            "fax_number": "417-883-0812"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KEVIN D WALLACE DMD, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-09",
        "last_updated": "2008-08-21",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "DENTIST",
        "authorized_official_telephone_number": "417-881-1123",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D.,P.C."
    },
    "taxonomies": [
        {
            "code": "1223P0700X",
            "taxonomy_group": "",
            "desc": "Dentist, Prosthodontics",
            "state": "MO",
            "license": "014935",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "WA405263807",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Springfield, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 21, 2008; 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.