1417176546 NPI number — MARY MICHELLE WALLACE N.P.

Table of content: MAGED G ZAKHARY DDS (NPI 1316135247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417176546 NPI number — MARY MICHELLE WALLACE N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
MARY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417176546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
444 N 44TH ST
Provider Second Line Business Mailing Address:
#200
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85008-7624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-685-3846
Provider Business Mailing Address Fax Number:
602-685-3808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 N 44TH ST
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85008-7624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-685-3846
Provider Business Practice Location Address Fax Number:
602-685-3808
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  RN030118 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 637184 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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