KEVIN R WALLACE DMD Dentist License verification

Business Entity

CANCELLED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****14

License Status

CANCELLED

Business

First Name

KEVIN R

Last Name

WALLACE

Suffix

DMD

Business Name

KEVIN R WALLACE DMD

Original Issue Date

04/04/1991

Effective Date

04/04/1991

Expiration Date

09/30/1992

City

CHICAGO

State

Zip

60641

County

COOK

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

10/13/2005