Healthcare Provider Details

I. General information

NPI: 1134126923
Provider Name (Legal Business Name): PETER WYLAN, D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10318 ROSECRANS AVE
BELLFLOWER CA
90706-2702
US

IV. Provider business mailing address

10318 ROSECRANS AVE
BELLFLOWER CA
90706-2702
US

V. Phone/Fax

Practice location:
  • Phone: 562-925-3765
  • Fax: 562-920-2493
Mailing address:
  • Phone: 562-925-3765
  • Fax: 562-920-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14411
License Number StateCA

VIII. Authorized Official

Name: PETER NMI WYLAN
Title or Position: D.D.S
Credential: D.D.S.
Phone: 562-925-3765