Healthcare Provider Details

I. General information

NPI: 1609894864
Provider Name (Legal Business Name): CHRISTOPHER ERIC WACKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25884 BUSINESS CENTER DRIVE #F
REDLANDS CA
92374
US

IV. Provider business mailing address

25884 BUSINESS CENTER DRIVE #F
REDLANDS CA
92374
US

V. Phone/Fax

Practice location:
  • Phone: 909-796-2507
  • Fax: 909-796-3247
Mailing address:
  • Phone: 909-796-2507
  • Fax: 909-796-3247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43267
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number43267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: