Provider Demographics
NPI:1871608604
Name:WALLACE, ANDREA L (DMD)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 S PLAZA RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9180
Mailing Address - Country:US
Mailing Address - Phone:208-365-3534
Mailing Address - Fax:208-365-6231
Practice Address - Street 1:2003 S PLAZA RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9180
Practice Address - Country:US
Practice Address - Phone:208-365-3534
Practice Address - Fax:208-365-6231
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-36561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8071026Medicaid