Healthcare Provider Details

I. General information

NPI: 1003935974
Provider Name (Legal Business Name): ROBERT STEVEN WYLIE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 S SEPULVEDA BLVD SUITE 1211
LOS ANGELES CA
90045-3807
US

IV. Provider business mailing address

8540 S SEPULVEDA BLVD SUITE 1211
LOS ANGELES CA
90045-3807
US

V. Phone/Fax

Practice location:
  • Phone: 310-670-5827
  • Fax: 310-670-1454
Mailing address:
  • Phone: 310-670-5827
  • Fax: 310-670-1454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number28834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: