Provider Demographics
NPI:1255421012
Name:WALLACE, JOSEPH FRANCIS III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:FRANCIS
Last Name:WALLACE
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-5620
Mailing Address - Country:US
Mailing Address - Phone:203-661-5858
Mailing Address - Fax:203-661-1159
Practice Address - Street 1:23 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5620
Practice Address - Country:US
Practice Address - Phone:203-661-5858
Practice Address - Fax:203-661-1159
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0407601223S0112X
CT70231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22414Medicare UPIN
NYD67912Medicare ID - Type Unspecified