Provider Demographics
NPI:1790843381
Name:WALLACE, KATHERINE AHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:AHN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11121 LOS ALAMITOS BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3603
Mailing Address - Country:US
Mailing Address - Phone:714-230-2434
Mailing Address - Fax:
Practice Address - Street 1:11121 LOS ALAMITOS BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3603
Practice Address - Country:US
Practice Address - Phone:714-230-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41055122300000X, 1223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry