Provider Demographics
NPI:1609894864
Name:WACKER, CHRISTOPHER ERIC (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ERIC
Last Name:WACKER
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 1:25884 BUSINESS CENTER DRIVE #F
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:909-796-2507
Mailing Address - Fax:909-796-3247
Practice Address - Street 1:25884 BUSINESS CENTER DRIVE #F
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374
Practice Address - Country:US
Practice Address - Phone:909-796-2507
Practice Address - Fax:909-796-3247
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA432671223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA900136449OtherTAX ID
CA855677OtherUNITED CONCORDIA