Provider Demographics
NPI:1871729186
Name:WALLACE, CAMERON S (DDS)
Entity type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:S
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 1:6127 N FRY RD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-5563
Mailing Address - Country:US
Mailing Address - Phone:281-550-3795
Mailing Address - Fax:
Practice Address - Street 1:6127 N FRY RD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-5563
Practice Address - Country:US
Practice Address - Phone:281-550-3795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice