Healthcare Provider Details

I. General information

NPI: 1043737430
Provider Name (Legal Business Name): MATHIAS STEPHEN FALLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S SEPULVEDA BLVD STE 216
MANHATTAN BEACH CA
90266-6976
US

IV. Provider business mailing address

500 S SEPULVEDA BLVD STE 216
MANHATTAN BEACH CA
90266-6976
US

V. Phone/Fax

Practice location:
  • Phone: 424-587-0472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number102159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: