Provider Demographics
NPI:1053428680
Name:WALLACE, KENNETH LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
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 1:4226 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-5601
Mailing Address - Country:US
Mailing Address - Phone:817-483-1133
Mailing Address - Fax:817-483-0388
Practice Address - Street 1:4226 LITTLE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-5601
Practice Address - Country:US
Practice Address - Phone:817-483-1133
Practice Address - Fax:817-483-0388
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX142631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice