Healthcare Provider Details

I. General information

NPI: 1528300340
Provider Name (Legal Business Name): DOUGLAS L WYLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E BONITA AVE
SAN DIMAS CA
91773-3004
US

IV. Provider business mailing address

115 E BONITA AVE
SAN DIMAS CA
91773-3004
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-2369
  • Fax: 909-592-6245
Mailing address:
  • Phone: 909-599-2369
  • Fax: 909-592-6245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: