Provider Demographics
NPI:1023143997
Name:LOTT, WALLACE RAY JR (DD,S)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:RAY
Last Name:LOTT
Suffix:JR
Gender:M
Credentials:DD,S
Other - Prefix:
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Mailing Address - Street 1:3610 LOMITA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3919
Mailing Address - Country:US
Mailing Address - Phone:310-373-6353
Mailing Address - Fax:310-373-6153
Practice Address - Street 1:3610 LOMITA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3919
Practice Address - Country:US
Practice Address - Phone:310-373-6353
Practice Address - Fax:310-373-6153
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA264661223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics