Healthcare Provider Details

I. General information

NPI: 1992119598
Provider Name (Legal Business Name): KONITA LEE WILKS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 11/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10602 CHAPMAN AVE
GARDEN GROVE CA
92840-3146
US

IV. Provider business mailing address

6021 KENWICK CIR
HUNTINGTON BEACH CA
92648-1036
US

V. Phone/Fax

Practice location:
  • Phone: 714-537-0700
  • Fax:
Mailing address:
  • Phone: 714-642-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number63433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: