Andrea L Wallace, D.M.D.

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D-3656 Issued in ID

Practice address

2003 S Plaza Rd
Emmett, ID 83617-9180

Phone

(208) 365-3534

Fax

(208) 365-6231

NPI assigned

Aug 20, 2006

Sex

Female

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

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

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.

• D & a Wallace, Inc.

  • Dentist
  • Emmett, ID
  • NPI 1144498437
  NPD (past) Authorized official
• Idaho Dental Professionals, P.C.

  • General Practice Dentistry
  • Emmett, ID
  • NPI 1467315275
  NPD (past)

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

{
    "created_epoch": "1156032000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1871608604",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2003 S PLAZA RD",
            "city": "EMMETT",
            "state": "ID",
            "postal_code": "836179180",
            "telephone_number": "208-365-3534",
            "fax_number": "208-365-6231"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2003 S PLAZA RD",
            "city": "EMMETT",
            "state": "ID",
            "postal_code": "836179180",
            "telephone_number": "208-365-3534",
            "fax_number": "208-365-6231"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "ANDREA",
        "middle_name": "L",
        "name_prefix": "Mrs.",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-08-20",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "ID",
            "license": "D-3656",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8071026",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Valley Family Health Care, Inc
• Valley Family Health Care, Inc
• Valley Family Health Care, Inc
• Elena Villanueva, LMSW
• Walgreen Co
• Darren K Wallace, D.M.D.
• Andrea Walsh, DNP, FNP-C
• Walter Knox Memorial Hospital
• Walter Knox Memorial Hospital
• Walter Knox Memorial Hospital

• General Practice Dentistry in Emmett, ID
• Providers in Emmett, ID by specialty
• General Practice Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; 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.