Provider Demographics
NPI:1053423285
Name:WALLACE, KEVIN R (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14831 W 159TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9008
Mailing Address - Country:US
Mailing Address - Phone:630-324-5369
Mailing Address - Fax:815-744-7059
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:STE 1103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-676-9893
Practice Address - Fax:815-744-7059
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022339122300000X, 1223G0001X
IL019-022339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1053431981OtherGROUP TYPE II NPI
IL1306177241OtherPRACTICE LOCATION TYPE II NPI
IL1205145554OtherPRACTICE LOCATION TYPE II NPI
IL1508198474OtherPRACTICE LOCATION TYPE II NPI
IL1760882005OtherPRACTICE LOCATION TYPE II NPI
IL1295165439OtherPRACTICE LOCATION TYPE II NPI
IL019-022339OtherDENTAL-IL
IL1063649770OtherGROUP TYPE II NPI
ILF400303856Medicare PIN