Provider Demographics
NPI:1881090892
Name:WALLIN, DEREK (DDS)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:WALLIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CENTURY PARK E STE 1601
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2019
Mailing Address - Country:US
Mailing Address - Phone:310-277-5678
Mailing Address - Fax:
Practice Address - Street 1:2080 CENTURY PARK E STE 1601
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2019
Practice Address - Country:US
Practice Address - Phone:310-277-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA638501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice