Healthcare Provider Details

I. General information

NPI: 1013139633
Provider Name (Legal Business Name): WYNDHAMSMITH AND KIM, APROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28097 SMYTH DR. SUITE C
VALENCIA CA
91355
US

IV. Provider business mailing address

28097 SMYTH DR. SUITE C
VALENCIA CA
91355
US

V. Phone/Fax

Practice location:
  • Phone: 661-291-1412
  • Fax: 661-291-1423
Mailing address:
  • Phone: 661-799-0925
  • Fax: 661-291-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number46195
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number41122
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number49312
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number32384
License Number StateCA

VIII. Authorized Official

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