MEDICARE: DR. RYAN CHRISTOPHER WALLACE D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	57224	CA

General Provider Information

NPI Number	:	1477875458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN CHRISTOPHER WALLACE D.D.S.

Provider Business Mailing Address
First Line	:	12300 WILSHIRE BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1020
Country	:	US
Telephone Number	:	310-393-8317
Fax Number	:	310-458-8804

Provider Business Practice Location Address
First Line	:	12300 WILSHIRE BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1020
Country	:	US
Telephone Number	:	310-597-0715
Fax Number	:	310-458-8804

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	06/12/2025

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