| Doctor Name: | MATTHEW SEYMOUR WALLACE |
| NPI Number: | 1861706145 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DDS |
| License Number: | |
| Business Practice Address: | 63 Geiger Rd Rome, NY - 134414324 |
| Business Phone Number: | 3153392120 |
| Business Fax Number: | |
| Mailing Address: | 63 Geiger Rd, ROME |
| State: | NY |
| Postal Code: | 134414324 |
| Phone Number: | 3153350164 |
| Fax Number: | |
| NPI Enumeration Date: | 07/29/2010 |
| NPI Last Update Date: | 08/08/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 390200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Student, Health Care |
| Taxonomy Classification: | Student in an Organized Health Care Education/Training Program |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who is enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure to provide health care. |