Provider Demographics
NPI:1750570107
Name:WALLACE, VICTOR F (DDS)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:F
Last Name:WALLACE
Suffix:
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 1:31 PUEBLO TRL
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:OH
Mailing Address - Zip Code:44644-9528
Mailing Address - Country:US
Mailing Address - Phone:330-863-4055
Mailing Address - Fax:330-863-4055
Practice Address - Street 1:31 PUEBLO TRL
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:OH
Practice Address - Zip Code:44644-9528
Practice Address - Country:US
Practice Address - Phone:330-863-4055
Practice Address - Fax:330-863-4055
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice