Provider Demographics
NPI:1730247222
Name:COLVIN, WALLACE SPURGEON III (DDS)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:SPURGEON
Last Name:COLVIN
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 1:69 SOUTHBOUND GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5545
Mailing Address - Country:US
Mailing Address - Phone:586-783-7000
Mailing Address - Fax:586-783-7003
Practice Address - Street 1:69 SOUTHBOUND GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-5545
Practice Address - Country:US
Practice Address - Phone:586-783-7000
Practice Address - Fax:586-783-7003
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010163471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4263930Medicaid