Provider Demographics
NPI: | 1922210632 |
---|---|
Name: | RYAN S. WALLIN, DDS, PC |
Entity Type: | Organization |
Organization Name: | RYAN S. WALLIN, DDS, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | BUSINESS MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | RONDA |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | ACCOLA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 480-218-8800 |
Mailing Address - Street 1: | 6626 E BASELINE RD |
Mailing Address - Street 2: | SUITE 101 |
Mailing Address - City: | MESA |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85206 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 480-218-8800 |
Mailing Address - Fax: | 480-218-7828 |
Practice Address - Street 1: | 6626 E BASELINE RD |
Practice Address - Street 2: | SUITE 101 |
Practice Address - City: | MESA |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85206 |
Practice Address - Country: | US |
Practice Address - Phone: | 480-218-8800 |
Practice Address - Fax: | 480-218-7828 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-05-04 |
Last Update Date: | 2008-03-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 5282 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |