Provider Demographics
NPI:1326535576
Name:RYAN WALLRICH DMD, PC
Entity Type:Organization
Organization Name:RYAN WALLRICH DMD, PC
Other - Org Name:HARBOR FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:WALLRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:619-405-5785
Mailing Address - Street 1:2322 CAMINITO ANDADA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1516
Mailing Address - Country:US
Mailing Address - Phone:619-405-5785
Mailing Address - Fax:
Practice Address - Street 1:1310 ROSECRANS ST STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-4609
Practice Address - Country:US
Practice Address - Phone:619-405-5785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100556261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental