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Contact Information

KEVIN R WALLACE, DMD
150 E HURON ST
STE 1103
CHICAGO, IL60611
 Phone: 312-676-9893
 Fax: 815-744-7059
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

General Practice

1223G0001X
 

Dentist

122300000X
Indicates primary specialty

NPI Profile & details for KEVIN R WALLACE · (Male)

NPI Number 1053423285
Status Active
Credentials DMD (Doctor of Medical Dentistry)
Entity Individual
Enumeration date 09/01/2006
Last updated 01/19/2021 - About 5 years ago
Sole proprietor 1 No
Identifiers
  • IL License # 019-022339
  • IL License # 019022339
  • IL Other 019-022339 DENTAL-IL
  • IL Other 1053431981 GROUP TYPE II NPI
  • IL Other 1063649770 GROUP TYPE II NPI
  • IL Other 1205145554 PRACTICE LOCATION TYPE II NPI
  • IL Other 1295165439 PRACTICE LOCATION TYPE II NPI
  • IL Other 1306177241 PRACTICE LOCATION TYPE II NPI
  • IL Other 1508198474 PRACTICE LOCATION TYPE II NPI
  • IL Other 1760882005 PRACTICE LOCATION TYPE II NPI
Hospital affiliation(s)
  • NORTHWESTERN MEMORIAL HOSPITAL - (Acute Care)
    251 E HURON ST
    CHICAGO, IL 60611
1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.

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