Active NPI
Ryan Christopher Wallace, D.D.S.
- Prosthodontics
- Los Angeles, CA
National Provider Identifier
1477875458
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Prosthodontics
- License
- 57224
- Practice address
- 12300 Wilshire Blvd Ste 400
Los Angeles, CA 90025-1020 - Phone
- (310) 597-0715
- Fax
- (310) 458-8804
- NPI assigned
- Feb 18, 2010
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Prosthodontics | 1223P0700X | 57224 | CA | Primary |
Addresses
Primary practice location
12300 Wilshire Blvd Ste 400
Los Angeles, CA 90025-1020
Mailing address
12300 Wilshire Blvd Ste 400
Los Angeles, CA 90025-1020
Phone (310) 393-8317
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 57224 | CA | MD | Surgical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Takumi J Kagawa DDS Inc | Prosthodontics | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Prosthodontics
- Los Angeles, CA
- NPI 1013205392
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1266451200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1749686400000",
"number": "1477875458",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "12300 WILSHIRE BLVD STE 400",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900251020",
"telephone_number": "310-393-8317",
"fax_number": "310-458-8804"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12300 WILSHIRE BLVD STE 400",
"city": "LOS ANGELES",
"state": "CA",
"postal_code": "900251020",
"telephone_number": "310-597-0715",
"fax_number": "310-458-8804"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "RYAN",
"middle_name": "CHRISTOPHER",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2010-02-18",
"last_updated": "2025-06-12",
"certification_date": "2025-06-12",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0700X",
"taxonomy_group": "",
"desc": "Dentist, Prosthodontics",
"state": "CA",
"license": "57224",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Los Angeles, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.