Active NPI
Chad Duane Wallace, D.D.S.
- General Practice Dentistry
- Rome, NY
National Provider Identifier
1912070335
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 051249
- Practice address
- 63 Geiger Rd
Rome, NY 13441-4324 - Phone
- (315) 339-2120
- Fax
- (315) 339-2120
- NPI assigned
- Nov 15, 2006
- 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 |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 051249 | NY | Primary |
Addresses
Primary practice location
63 Geiger Rd
Rome, NY 13441-4324
Mailing address
63 Geiger Rd
Rome, NY 13441-4324
Phone (315) 339-2120
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02620184 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NY
- 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 |
|---|---|---|---|---|
| I20160112003045 | NY | Order and Referring Only - Oral Surgery | 2466754148 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 051429 | NY | MD | Prosthodontist |
| 051249 | NY | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163548800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1912070335",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "63 GEIGER RD",
"city": "ROME",
"state": "NY",
"postal_code": "134414324",
"telephone_number": "315-339-2120",
"fax_number": "315-339-2120"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "63 GEIGER RD",
"city": "ROME",
"state": "NY",
"postal_code": "134414324",
"telephone_number": "315-339-2120",
"fax_number": "315-339-2120"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "CHAD",
"middle_name": "DUANE",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-11-15",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NY",
"license": "051249",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "02620184",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Rome, NY
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.