Provider Demographics
NPI:1457488132
Name:ANDELIN, WALLIS E (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:WALLIS
Middle Name:E
Last Name:ANDELIN
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Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:16168 BEACH BLVD
Mailing Address - Street 2:SUITE 90
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-3816
Mailing Address - Country:US
Mailing Address - Phone:714-847-8488
Mailing Address - Fax:714-847-1582
Practice Address - Street 1:16168 BEACH BLVD
Practice Address - Street 2:SUITE 90
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-3816
Practice Address - Country:US
Practice Address - Phone:714-847-8488
Practice Address - Fax:714-847-1582
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2010-08-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA332291223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA201572100Medicare UPIN
CA481272532Medicare UPIN