Provider Demographics
NPI:1497901995
Name:WALLIS, CHRISTOPHER RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:RYAN
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1125 W KAGY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5881
Mailing Address - Country:US
Mailing Address - Phone:406-585-1120
Mailing Address - Fax:406-587-1988
Practice Address - Street 1:1125 W KAGY BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5881
Practice Address - Country:US
Practice Address - Phone:406-585-1120
Practice Address - Fax:406-587-1988
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT115031223S0112X
OH30.0228111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery