Provider Demographics
NPI:1477875458
Name:WALLACE, RYAN CHRISTOPHER (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:CHRISTOPHER
Last Name:WALLACE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 3RD ST STE 1008
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1648
Mailing Address - Country:US
Mailing Address - Phone:213-625-7141
Mailing Address - Fax:213-625-7167
Practice Address - Street 1:420 E 3RD ST STE 1008
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1648
Practice Address - Country:US
Practice Address - Phone:213-625-7141
Practice Address - Fax:213-625-7167
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA572241223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics