Provider Demographics
NPI:1447266218
Name:WALLACK, MILTON B (DDS)
Entity type:Individual
Prefix:DR
First Name:MILTON
Middle Name:B
Last Name:WALLACK
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 1:295 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3025
Mailing Address - Country:US
Mailing Address - Phone:203-288-8221
Mailing Address - Fax:203-230-0849
Practice Address - Street 1:295 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3025
Practice Address - Country:US
Practice Address - Phone:203-288-8221
Practice Address - Fax:203-230-0849
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0037771223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061025204OtherTAX ID NUMBER