Provider Demographics
NPI:1821510728
Name:WALLIS, JON RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:RYAN
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 E YEAGER DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1613
Mailing Address - Country:US
Mailing Address - Phone:520-424-1955
Mailing Address - Fax:
Practice Address - Street 1:2028 N TREKELL RD STE 107
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-1326
Practice Address - Country:US
Practice Address - Phone:520-876-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist