Healthcare Provider Details

I. General information

NPI: 1508088675
Provider Name (Legal Business Name): DAVID R. WYNDHAMSMITH, A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1092 E GREEN ST
PASADENA CA
91106-2506
US

IV. Provider business mailing address

1092 E GREEN ST
PASADENA CA
91106-2506
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-5140
  • Fax: 626-395-5144
Mailing address:
  • Phone: 626-395-5140
  • Fax: 626-395-5144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number41122
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number49312
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number37519
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number46195
License Number StateCA

VIII. Authorized Official

Name: MRS. PATRICE A WYNDHAMSMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 626-795-9328