Provider Demographics
NPI:1043880438
Name:WALLACE, DEANNA T (RDH)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:T
Last Name:WALLACE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2981
Mailing Address - Country:US
Mailing Address - Phone:608-314-1930
Mailing Address - Fax:
Practice Address - Street 1:1344 CRESTON PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-1113
Practice Address - Country:US
Practice Address - Phone:608-314-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5054-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist