Provider Demographics
NPI:1306801683
Name:WALLIN, RYAN SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:SCOTT
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 1:1914 S POWER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4376
Mailing Address - Country:US
Mailing Address - Phone:480-218-8800
Mailing Address - Fax:480-218-7828
Practice Address - Street 1:1914 S POWER RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4376
Practice Address - Country:US
Practice Address - Phone:480-218-8800
Practice Address - Fax:480-218-7828
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD52821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice