Provider Demographics
NPI:1245127331
Name:WALLACE, MARY C (DDS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 HOGAN DR APT 3707
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75709-6964
Mailing Address - Country:US
Mailing Address - Phone:903-805-9767
Mailing Address - Fax:
Practice Address - Street 1:5540 OLD JACKSONVILLE HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3378
Practice Address - Country:US
Practice Address - Phone:903-597-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX414681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice