Healthcare Provider Details

I. General information

NPI: 1821398587
Provider Name (Legal Business Name): KRISTINA L. WILEY, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 N JACKSON ST SUITE 1
DIXON CA
95620-3034
US

IV. Provider business mailing address

140 N JACKSON ST SUITE 1
DIXON CA
95620-3034
US

V. Phone/Fax

Practice location:
  • Phone: 707-678-9248
  • Fax: 707-678-9274
Mailing address:
  • Phone: 707-678-9248
  • Fax: 707-678-9274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number41149
License Number StateCA

VIII. Authorized Official

Name: DR. KRISTINA L. WILEY
Title or Position: CEO/ OWNER
Credential: D.D.S.
Phone: 707-678-9248