Healthcare Provider Details

I. General information

NPI: 1740331933
Provider Name (Legal Business Name): DR. CLERA SUSAN WIJEWARDENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 E LOS ANGELES AVE
SIMI VALLEY CA
93065-2866
US

IV. Provider business mailing address

11845 STONE GATE WAY
PORTER RANCH CA
91326-4033
US

V. Phone/Fax

Practice location:
  • Phone: 805-527-8991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number37754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: