Kevin D Wallace, DMD PC

Primary specialty

ProsthodonticsTaxonomy code 1223P0700X

License

014935 Issued in MO

Practice address

1200 E Woodhurst Dr Ste A200
Springfield, MO 65804-3745

Phone

(417) 881-1123

Fax

(417) 883-0812

NPI assigned

Aug 21, 2008

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

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

{
    "created_epoch": "1219276800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1219276800000",
    "number": "1972750909",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 E WOODHURST DR STE A200",
            "city": "SPRINGFIELD",
            "state": "MO",
            "postal_code": "658043745",
            "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 STE A200",
            "city": "SPRINGFIELD",
            "state": "MO",
            "postal_code": "658043745",
            "telephone_number": "417-881-1123",
            "fax_number": "417-883-0812"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "KEVIN",
        "middle_name": "D",
        "name_prefix": "Dr.",
        "credential": "DMD PC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2008-08-21",
        "last_updated": "2008-08-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0700X",
            "taxonomy_group": "",
            "desc": "Dentist, Prosthodontics",
            "state": "MO",
            "license": "014935",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Christian Wall, MS CF-SLP
• Ashley D Wallace, M.S., PLPC
• Bridget Rena Wallace
• Hannah L Wallace, MS, BCBA
• Karen Wallace
• Lacey Jo Wallace, MS, PLPC
• Morgan Dawn Wallace, PA-C
• Nicole Lee Wallace, PTA
• Samantha Wallace, DO
• Sherrie K Wallace, MSW, LCSW

• Prosthodontics in Springfield, MO
• Providers in Springfield, MO by specialty
• Prosthodontics in Missouri

• 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.